What Does a Medical Claims Auditor Do?

You might not be familiar with what a medical claims auditor does, but they're an incredibly common part of the US healthcare system. The job usually requires a bachelor's degree in accountancy or a commerce-related field and at least three years of claims auditing experience. With a strong employment outlook and a decent starting salary, it's a growing industry with plenty of career opportunities. Medical auditing doesn't get much attention when discussing healthcare careers, so it's understandable that a lot of people don't know what exactly they do or how claims auditing works. Given that whether your insurance claim is accepted or rejected depends entirely on medical claims auditors, it's important for anyone to understand their role in the healthcare industry.

What is a medical claims auditor?

Following a visit to the doctor, patients submit a claim to their insurance provider which explains what care was given, how much it costs, and details of what is covered by the patient's insurance. A medical claims auditor's role is to follow up on that claim to ensure the paperwork submitted is complete and that the pricing is accurate. The auditor is essentially a medical coding professional who ensures that claims, records, and documentation demonstrate compliance with both industry and federal standards. Generally, it's a career that requires an analytical mind and high-level problem-solving skills. A commitment to honesty and integrity and the ability to exercise good judgment are also essential to success. From a practical perspective, data management experience, computer knowledge, and expertise in MS Excel and MS Word are prerequisites.

What do medical claims auditors do?

A medical claims auditor, essentially, is a safeguard against insurance fraud. Sometimes forms contain mistakes or fields are missing necessary information and you'll need to get in touch with the doctor or the patient to provide you with the answers required. Occasionally, you will find amounts on claims that seem suspiciously high, and those cases will usually be turned over to someone with the supervisory authority to investigate further. In investigating claims, you must keep detailed and clear records. If a lawsuit occurs, it's necessary for you to be able to demonstrate exactly how you performed your investigation and came to a conclusion. In a governmental role, auditors can even recommend sweeping policy changes that could affect millions of people. If medical integrity is important to you, you might find a career in medical claims auditing to be deeply rewarding and a perfect match for your skills.

On the day to day, you'll do things like review processed claims prior to payment release and handle communication with various HMOs (health maintenance organizations). You'll be responsible for ensuring compliance with Medicaid and Medicare as well, so it's important to have a background or knowledge of topics related to public health programs. Most job descriptions (like this expired one) suggest that a couple of years of experience are necessary to get a real start in the industry.

Medical claims auditing is an important part of our insurance billing process in the United States, and claims auditors have to be trained in various types of data management, accounting, and healthcare protocol in order to effectively safeguard against insurance fraud. Medical claims auditors protect patients, hospitals, and insurance providers from the submission of false records, price gouging, and other types of fraud. If you're interested in a career in the industry, the respectable starting salary, opportunity for advancement, and growing job market are great reasons to give it serious consideration. If you're the owner of a hospital, HMO, or other healthcare organization that requires compliance with state, federal, or industry standards, make sure you have a well-qualified medical claims auditor on your staff.

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