Medical Claims Analyst Jobs

A Medical Claims Analyst works in the insurance industry to determine levels of reasonable and necessary charges for all medical claims. These are then used when ascertaining which costs will be covered by a medical insurance policy.

Nature of the Work

A Medical Claims Analyst is responsible for maintaining “cost containment” for their employer, usually an insurance company. Cost containment is basically the ability to keep costs (payout for medical insurance claims) to a minimum in order to provide a reasonable profit for the insurance company.

In order to determine whether specific medical/surgical bills are reasonable and necessary, a medical claims analyst evaluates what the “usual and customary” billings are; these are then used to determine what amount will be paid when a claim is filed. Items which are reviewed and analyzed may include: length and appropriateness of hospital stay, surgical procedures, claims referred for medical management, appropriate follow-up physician visits, and similar items.

Analysts may also perform a second review of claims which have been denied in whole or in part to determine the appropriateness of the payments authorized, or interpret the Workers’ Disability Compensation Act to determine eligibility. They may also be required to attend hearings or mediations to defend the decisions made if they are disputed.

Analysts prepare reports and records which analyze and interpret data related to claims quality of service, as well as produce forecasts of claim receipts.

Training and Qualifications Needed√£EUREUR

Most Medical Claims Analyst jobs require a bachelor’s degree in nursing, physician assistant, pharmacy, or business administration or the equivalent combination of education and experience with several years claims analysis experience. Opportunity For Advancement

After working at an entry level analyst job for several years, a typical career path would be to become a lead supervisor over a group of analysts, perhaps eventually promoting to senior supervisor over a department.

Long Term Job Outlook

With the healthcare industry experiencing greater than average growth, these jobs should continue to offer good long term potential. In addition, with the potential of the new national healthcare system, more analysts may be needed to ensure the appropriate levels of care are met.

Salary and Earnings Potential

Medical Claims Analysts make an average of $53,000, with a range of mid $40k to low $60k. Differences depend on geographical location and experience. A working knowledge of medical billing claims terminology, and the medical claims process is necessary. In addition, a strong base in mathematics and statistics is desirable.

Healthcare Staffing Companies Poised For Growth Amid Nursing Shortage

The United States is currently facing a healthcare staffing crisis, based primarily in a shortage of nurses. There is a growing need for nurses, especially travel nurses, and the problem is anticipated to become more acute in the next year. Since 2006, patients have won significant settlements from hospitals for negligence due to nursing shortage, and as the cost of hiring too few nurses comes to outweigh the cost of adequately employing, healthcare staffing companies should have definite growth.

People who feared that healthcare staffing would slow in today’s shaky economy and sold their shares in such companies now regret the decision, as these businesses have jumped in value. Shares of several companies providing travel nurses and temporary physicians initially fell due to fear in our current recession, but have since rebounded sharply.

According to BMO Capital Markets analyst Jeffrey Silber, “an aging population and advances in medical technology should drive demand, while supply may be constrained as caregivers age with few replacements coming through the pipeline. This should bode well for healthcare staffing supplier stocks.”

Silber estimated a travel-nurse staffing revenue of $2.5 billion annually, which is 21 percent of total healthcare staffing revenue. The growth forecast for travel nurses is set particularly slow as tough times push people towards stable jobs at home. He also pointed out that growth in the travel-nursing segment is estimated at 3.5 percent in 2009, compared with 8 percent in 2006.

This has not, however, affected many healthcare staffing companies. For hospitals to even maintain current (depleted) numbers of nurses, they must continue to hire new nurses on a regular basis. The U.S. Bureau of Labor Statistics reported that the median age of registered nurses (RNs) was 45 years in 2007. Also, another study reported that a third of all current nurses plan to leave their job within the next year.

Furthermore, staffing companies specializing in travel nurses are expected to continue to do well financially because of the nature of the job of travel nurse. These healthcare workers are employed by hospitals from around one to four months, so staffing companies increase their profit margins because of the rise in billed rates.