Job Profile: Insurance Specialist

Medical treatment is an expensive endeavor in the United States. According to Investopedia, one of the most pricey healthcare procedures is a heart transplant, which costs $787,700 on average! Health insurance coverage is imperative to afford life-saving procedures like this. You never know when disease or complications will arise, but being insured will reduce at least the financial burden. Healthcare providers hire insurance specialists to help patients pay. It's their duty to assess the insurance policy held by patients and ascertain costs due. Deciphering complex insurance laws and regulations is their bread and butter. Insurance specialists work closely with the facility's billing team to review charges and submit claims to the patient's carrier. Quickly garnering reimbursement for the medical services provided without bankrupting patients is the insurance specialist's goal.


Statistics on show that insurance claims specialists employed in the United States bring home a median annual salary of $44,835. This is equivalent to a mean hourly wage of $22, or $862 per week. Insurance specialists typically earn bonuses, social security, retirement plans, healthcare, and vacation for total yearly compensation at $69,728 on average.

Beginning Salary

When first entering the health insurance arena, specialists can expect landing in the bottom quarter percentile of earnings for under $37,008. Although that's low, remember that insurance specialists with years of experience can eventually earn base salaries over $60,685. Those who advance into coveted executive positions like Chief Claims Officer make $186,029 per year.

Key Responsibilities

Insurance specialists occupy most medical offices to correctly calculate patients' out-of-pockets like co-pays and process healthcare claims to respective carriers. They use the medical codes placed on patient records to judge the level of insurance coverage extended. Using electronic health records, insurance specialists analyze billing information to detect mistakes and update any changes. Insurance specialists must link ICD-10-CM codes to justify the organizations reason for performing the procedures on the claims form. When claims are denied, insurance specialists will spearhead the appeals process on behalf of the patient. Other responsibilities include following HIPAA laws, posting payments on patient accounts, overseeing practice cash flow, and watching for fraud.

Necessary Skills

Success in medical insurance claims will require building the coding language skills to assess patient records for treatment repayment. Insurance specialists must have the research and analytical skills to form accurate claims paperwork. Typing skills must be exceptional for insurance specialists to avoid costly typos in dollar amounts. Insurance specialists need good written and oral communication skills to convey messages to insurance carriers and clinicians. Active listening skills are another must for understanding patient concerns and properly answering their claims questions. Organizational abilities are important for insurance specialists to keep claims records tidy and accessible for review. Basic mathematical skills are also required by insurance specialists to ensure apt reimbursement.

Degree and Education Requirements

Becoming an insurance specialist will usually require education beyond a high school diploma or GED. Healthcare organizations prefer hiring insurance specialists with an associate degree from an accredited community college or vocational school. Majoring in insurance services, claims, finance, medical billing, or health informatics will be suitable. Those going the latter route should find a CAHIIM-accredited program for training excellence. Earning a four-year bachelor's degree may accelerate advancement into mid-level insurance claims jobs. Insurance specialists could later return for a Master of Health Administration (MHA) to open doors for executive titles like health insurance director or Chief Insurance Officer.

Pros and Cons of the Position

Taking the steps to become an insurance specialist will deliver advantages with potential drawbacks to consider. In the pro column, insurance specialists are entering a healthcare field with above-average job growth. Decent salary potential is supplemented with good benefits, especially healthcare insurance. Jobs are available at health-related organizations virtually anywhere, even overseas. If desired, insurance specialists with experience can switch into other industries like real estate or automotive. Education requirements are minimal for entry-level work, but there's plenty of room for advancement. In the con column, insurance specialists have a desk job that requires significant time sitting behind a computer. Minimal patient contact could be disappointing for extroverted individuals. Keeping up with the latest insurance changes may be overwhelming and stressful for some. Insurance specialists sometimes negotiate with carrier representatives after rejecting claims. Job competition is also heating up as many graduates are drawn into healthcare.

Getting Started

Having at least one to two years of experience in healthcare is generally required. Insurance specialists should bulk up their resume with internships and co-operatives in medical offices. Job training entering patient data, coding diagnoses, and adding up bills is vital. Many insurance specialists in healthcare begin as entry-level medical coders or billers before advancing. Being able to highlight healthcare qualifications to the hiring manager will be beneficial. You can then move into medical insurance processing in inpatient or outpatient settings. Professional certification is voluntary, yet highly recommended. For instance, the Practice Management Institute offers the Certified Medical Insurance Specialist (CMIS) credential. This online course proves coding expertise and requires frequent CEUs. Insurance specialists could also become Registered Health Information Administrators (RHIA) for advancement.

Future Outlook

Since the Affordable Care Act (ACA) was passed in 2010, there's been strong enrollment in the health insurance marketplace. Around 16.4 million uninsured Americans have gained access to insurance coverage. Over 12.3 million more have enrolled in Medicaid and CHIP. In 2014 alone, uncompensated healthcare costs dropped by $7.4 billion! These trends show that there's a glut of opportunity for insurance specialists in the medical field. They'll remain in high demand to process claims for insured patients receiving physicals, lab tests, treatments, surgeries, and long-term rehabilitation. The Bureau of Labor Statistics projects that healthcare jobs for insurance specialists will grow by 15 percent over the next decade. Insurance specialists could work in hospitals, surgical centers, medical group practices, insurance companies, managed care, mental health clinics, and more.

Insurance specialists, sometimes called claims coordinators or billing specialists, are skilled medical staff who classify patient records to facilitate proper reimbursement. They process sensitive, confidential information through secure databases to file claims with insurance companies. Insurance specialists navigate the complicated claims process on patients' behalf and resolve any billing headaches. Deciding to become an insurance specialist will provide an in-demand, rewarding career keeping patients satisfied and health organizations profitable.

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