Doctor's offices, hospitals and other medical providers typically file medical claims for their patients. Once the insurance company receives the claim, a claims processor reviews it for errors and determines if it is eligible for payment based on the patient's health insurance policy. A claims manager runs the claims department, while performing many of the same duties as the processors.
Different insurance companies have different educational requirements for medical claims managers. As a general rule, however, candidates should have a bachelor’s degree in business, finance, accounting or management. Some companies might accept an associate degree for candidates who have a strong background in medical claims processing or coding and billing. Some states require that claim personnel be licensed. The criteria for licensure vary from state to state, but often include an exam and certified education credits.
The main duty of the claims manager is to review medical claims submitted by policyholders or medical facilities for payment. This includes verifying patient and physician information. It also includes ensuring that the correct current procedural terminology, or CPT, and international classification of disease, or ICD-9, codes are used. The claims manager also ensures the codes listed are for actual services performed and meet medical necessity. This helps protect the insurance company from fraudulent billing. The manager often requests a copy of the patient’s medical records for verification.
Claims managers must be very organized to be successful. They maintain files of claims and make sure the information is readily available. Also, claims managers need strong communications skills. On any given day the manager may correspond with physicians, policyholders or billing specialists. The correspondence may be via written or verbal means, including email, postal mail, fax or telephone. The ability to multitask is also a necessity since claims managers often juggle several claims at a time.
The claims manager often has a group of employees working under him. In this role, he might oversee scheduling, hire and train new employees, and intervene if employee conflict arises. The manager reviews medical claims denied or approved by the employees for errors. He also conducts employee reviews and evaluations when necessary. In addition, the manager creates and maintains financial reports for the claims department. This includes the number of claims received and the amount paid or denied.