Based on the nature of their work, health claims examiners need to have a solid understanding of the health claim, insurance, and health referral systems. They can find work in private or government settings. Licensing or certification may be required.
A health claims examiner's primary job duty is to determine if insurance claims should be approved or denied. Most health claims examiners are trained on the job, but there are undergraduate education options that may help an examiner to be more competitive in the job market. Some states regulate health claims examiners through certification or licensing.
|Required Education||Variable; a high school diploma and on-the-job training OR an associate's or bachelor's degree in a healthcare-related discipline|
|Licensure or Certification||Required in some states|
|Projected Job Growth (2018-2028)*||-4% (for claims adjusters, appraisers, examiners, and investigators)|
|Median Annual Salary (May 2018)*||$65,900 (for claims adjusters, examiners, and investigators)|
Source: *United States Bureau of Labor Statistics
Health Claims Examiner Jobs Career Options
A health claims examiner is in charge of reviewing insurance claims to ensure they are valid. An examiner may send a claim to be investigated if he or she believes there is reason to doubt the validity of a claim. Many health claims examiners work for insurance providers; however, there are available job opportunities with government agencies, businesses, and health care facilities.
Health claims examiners have the same general job duties no matter what type of company or agency they work for, which include:
- Reviewing claims for errors
- Ensuring policy coverage for claims
- Gathering information about a claim
- Making recommendations to approve or deny claims
- Creating reports for claims
- Referring claims to investigators
In 2018, according to the U.S. Bureau of Labor Statistics (BLS), 328,500 jobs were held by adjusters, appraisers, examiners and investigators (www.bls.gov). The BLS reported that a large percentage of those jobs were with insurance carriers. The Bureau reported the annual median salary earned by claims adjusters, examiners, and investigators as $65,900 in May 2018; those working for insurance carriers earned an average of $67,210 a year. The projected job growth for this field from 2018 to 2028 was projected to decline four percent, according to the BLS.
Health Claims Examiner Jobs Requirements
A high school diploma or equivalent is required for employment as a health claims examiner. Employers usually do not require a college degree for entry-level positions. Health claims examiners usually learn through on-the-job training.
Health claims examiners need to have knowledge of medical terminology, coding, and billing. Additionally, an examiner needs to have skills in computers, mathematics, and data entry. Many community colleges or vocational schools offer programs in medical billing and coding which can help a person to gain the skills necessary to get a job as a health claims examiner. There is also the option of obtaining an associate's or bachelor's degree in a medical related field.
In some states, health claims examiners must be licensed or certified. The regulations for licensing and certification are set at the state level. Some states mandate that examiners must be certified through an exam and meet continuing education requirements.
Health claims examiners often work in an office setting, but may find themselves travelling to investigate suspicious claims. Most training for their work is conducted on the job, but because of the need to understand medical terminology and billing, a program in medical coding can be helpful for experience. They may have to meet specific standards for certification or licensure in some states.