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What is the role of a health insurance specialist?

“To sum it up…”

  • The duties of a health insurance specialist explained in direct terms
  • Training and qualifications a health insurance specialist must complete in qualifying for the position.
  • The reasons you may need to speak to a health insurance specialist
  • Health insurance is more than a policy. It is about having a healthcare team

Health insurance specialists are responsible for handling paperwork, records, and additional information germane to your insurer and you. They gather these documents to then compare to claims made by health care providers.

Specialists are trained to read coding from physicians to decipher if the claim is payable or if there are errors in which would cause a denial of payment.

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The Role of a Health Insurance Specialist


Many health insurance specialists have prior experience in the fields of computer science or healthcare. The fundamental skills are building blocks for someone seeking the title of expert.

Communication skills are essential for a health insurance specialist because they are the go-between your doctor and insurance company. In some cases, coding is incorrect, and it is the professional’s job to find the mistakes.

If you were to challenge a refusal to pay a claim, you would also likely speak to a health insurance specialist because they have possession of your information, records, and insurance policy in one place.

Examining your doctor bills are important. Mistakes happen, and even doctors or insurance specialists may miss something that could cost you in the long run. If you do believe there is an error, it is your right to contest the refusal with the insurance company. A specialist will then work with your doctor to go over the bill and ensure you are well represented.

Requirements To Be A Health Insurance Specialist


Most insurance companies require their health insurance specialist to have a degree expressly directed in the field of health insurance. Experience with communication, computers, and coding systems are also requirements because of the heavy responsibilities that rely directly on the specialist.

The reason experience in communication is important is not only because they communicate directly with doctors, but they also are responsible for explaining coverage and issues with medical patients in a factual and understanding way.

Advanced computer skills are needed by a specialist because they are responsible for inputting, updating, transmitting, and storing health insurance claim information.

Most colleges and universities offer degree programs that specifically are directed towards those wanting to work in the medical insurance field. A specialist concentrates on the skills required directly for that position.

Many specialists either obtain a Certified Professional Coder certification, also known as a CPC, while attending college or after entering the health insurance field. You have the right the know what certifications, qualifications, and compliances your health insurance company possess.

You and Health Insurance Specialists


Healthcare requires a team. From doctors to health insurance specialists, each step of the insurance process and person involved plays a role in your wellbeing.

When in search for a health insurance policy, researching and asking questions is always the first step. Now that you know what a health insurance specialist is responsible for, you may have additional questions to ask when shopping around for quotes or your current insurer.

Doctor offices sometimes incorrectly code procedures or visits. When the insurance company receives the request for payment, the specialist only goes by what you physician provides.

Often, the insurance agency will call the doctor’s office to double check the coding before denying a claim. However, in some instances, it sneaks through, and you will receive a bill.

Human error is hard to avoid. But you now know the point of contact with your insurance company is the health insurance specialist when there are issues with a claim denial. They have all of your information stored as to access it easily and remedy any problems that arise.

You may not always feel in control of your medical bills and insurance, but you are. From the doctor to the claim paid, each step for your benefit.

The reason a health insurance specialist is an important member of your healthcare team is that they are responsible for catching the human errors and correcting them so that your claim goes through with full payment.

Your Health Advocate


You are your best advocate. However, having a team that is trained and ready to make your life easier proves to be the best route.

With a health insurance specialist, you have a certified go-between that will keep you in the loop while also correcting, collecting, and collaborating with your physicians to keep you healthy.

You may already have insurance, or you are preparing to find health coverage that best covers you. In either case, appropriate coverage is the utmost priority. However, you also want to be insured properly at the lowest cost possible.

You also want to be assured of compliance with state, federal, and local legislature as it relates to health insurance. Transparent accountability and service are also important. Its importance is not merely for you, but also for your doctors and caregivers.

While health insurance specialists’ responsibilities are broad and extensive, they are there to take the burden of proof off of you and to ensure your healthcare providers are not overcharging, incorrectly charging, or making simple errors.

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  1. http://www.hhs.gov/
  2. http://delmarlearning.com/companions/content/1418067067/student/chapter%201.pdf
  3. http://study.com/articles/Health_Insurance_Specialist_Job_Description_and_Requirements.html
  4. http://www.ahima.org/certification/CCS