Medical Claim Examiner

A career in medical claims examination might be a good choice for detail oriented individuals with excellent administrative skills and knowledge of medical terminology. Health claims specialists usually work for health insurance companies, health care providers, and hospitals. They are responsible for reviewing all insurance claims to ensure information integrity, adherence to standard guidelines and timeliness of processing. Depending on their appraisal of the claim, medical claims examiners then approve payment or facilitate further investigation. Many employers require just a high school diploma, but some call for more advanced education through a certificate program in medical billing technology or a relevant field. Individuals in these jobs need good customer service and communications skills, as well as knowledge of computer software, medical insurance coding, insurance and medical terminology. Professional certification in this field is not mandatory, but could boost career advancement.

Average Hourly

$42.17

Range Hourly

$26.33-$58.51

Average Yearly

$81,956

Range Yearly

$51,343 – $114,094

NOC Code

Medical Insurance Adjuster and Claims Examiner (1312)

Alias Job Titles

Patient Advocate – Health Advocate – Health / Medical Claims Examiner

Qualifications Required

· Experience in any of the following:
· Medical terminology training or experience in the medical field is considered an asset
· Fluency in English; bilingual (French) is an asset

Job Demand

Medium
Employment outlook is good to fair in most provinces. More information is available here.

Growth opportunity

Medical claim examiner may sometimes need to begin as clerical workers or telephone adjusters in the claims departments of insurance companies or in independent adjusting firms, and gradually expand their knowledge and experience in the field.

With additional training, one can be promoted to claims examiners, field adjusters, supervisors or claims managers.

Years’ Experience Required

1-2 years post graduate training and experience are usually required

Training Options (if available)

CIP (Chartered Insurance Professional)
FCIP (Fellow Chartered Insurance Professional)

Personal Qualities

•Medical claims examiners must be extremely detail-oriented, precise and thorough. Must be organized, analytical, and decisive.
• Need strong oral and written communication skills
• Need good interpersonal skills, especially when you work with clients who are upset or experiencing stress.
• Must be able to work as part of a team.
• Knowledge of medical terminology and computer skills are helpful
• A broad understanding of health insurance administration processes
• standard guidelines, such as the average hospital stay for certain procedures or standard treatments for common illnesses.
• Medical claims examiners must possess good judgment and integrity, as their review of an insurance claim acts as the final approval of payout and the ultimate determinant of cost to the insurance company.

Notes/Other Information

Additionally, these specialists must be familiar with diagnostic coding systems and coding procedures.

Potential employers /Workplaces

- Health insurance companies
- Health care providers
- Hospitals

Steps towards capacity building to become competitive for this job

IMG’s to be granted this job need to perform their knowledge about insurance processes and coding system through CIP/FCIP Training courses. It is possible to start as a Clerk in the Claims Department and get on-the-job training and completion of insurance industry courses and training programs.