Medical Claims Reviewer Jobs

Medical Claims Reviewer jobs can be found in a number of places: hospitals or medical provider offices, insurance companies, or in an independent auditor capacity.

Nature of the Work

People employed in Medical Claims Reviewer jobs work to determine if medical claims have been paid with accuracy. The reviewer typically focuses on patient bills that exceed usual and customary charges to ensure that either insurance companies are only charged for services rendered, or that providers are billing for all the services they have performed. By comparing medical records with bills generated, the medical claims reviewer can verify the payment accuracy.

Another task Medical Claims Reviewers perform is to review and investigate denied claims. The reviewer then determines why the medical procedure was denied and resolves the issue by providing documentation either supporting approval or denial of the services delivered.

Disability claims reviewers may also perform investigations in the course of their jobs to determine both qualifications for receiving a disability insurance claim and also to prevent fraud. The claims reviewer will question a claimant to determine eligibility for a long term disability income benefit claim, and may dig deeper by interviewing neighbors, obtaining and reviewing medical, employment, Social Security, or Workers' Compensation records. Some claims reviewers will also conduct surveillance; for example, videotaping the claimant at work or in public.

Training and Qualifications Needed

Entry level jobs require a high school diploma at minimum, but most employers prefer candidates possess a four year college degree, preferably an RN or another medical field. Knowledge of medical billing and coding and claims processing are usually required, although entry level jobs may provide training. Candidates should understand Medicare Part A and B and Medicaid payment methods.

Opportunity for Advancement

In each of the available avenues available for claims reviewers (hospital, insurance agency, independent auditor capacity), the typical career path is to work your way up from entry-level position to overseeing the claims review department, with a number of advancement steps along the way, depending on the size of the organization. Potential is also available to open either a medical billing business or independent medical claims review auditor business.

Long Term Job Outlook

Medical claims reviewer jobs will continue to be plentiful as the healthcare industry continues to expand. The need for accurate and complete billing, which provides maximum profits for both insurance companies and providers alike, will drive the need for reviewers for a number of years to come, making this a good career option.

Salary and Earnings Potential

The average salary for medical claims reviewer jobs in the US is $48,000, with a range from around $40k to the upper $50k's. Differences in salary are based on geographical location and experience.


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