What Does a Health Insurance Specialist Do?

A health insurance specialist generally assists health care providers with organizing information involved in claims or other documentation. To do this, these kinds of professionals need detailed knowledge about how various health insurance companies work, as well as competency in a wide range of medical codes and protocols. Clinical or clerical experience in a medical environment can also be critically important in an individual’s success as a health insurance specialist.

Professional health insurance specialists in medical offices often explain their jobs by referencing recent phenomena in the health care and health insurance fields. One of these is the complexity of health insurance claims, which get billed to national health care programs in many countries. Other issues include new practices by private health insurance companies to change how payments are made for claims. The general task of the health insurance specialist involves sorting out which issues are challenging a health care provider, and addressing them through competent handling of documentation.

Along with streamlining insurance documents and facilitating insurance payments, a health insurance specialist needs to understand the government regulations that involve handling patient health data. For example, in the U.S., the HIPAA (Health Insurance Portability and Accountability Act) is something that health insurance specialists need to know about and comply with. Other internal regulations may also apply, where organizations like the Joint Commission of Accreditation on Hospitals (JCAHO) set up guidelines for hospitals and other facilities, according to their national or regional jurisdictions.

Specialists in health insurance need to know about how doctors and other health care workers document diagnosis and treatment of patient issues. They need to understand how health insurance claims and explanation of benefit (EOB) forms are put together. All of this takes significant study in conventions like International Classification of Disease (ICD) coding, Current Procedure Terminology (CPT) procedure coding, and the use of various forms in a national or regional context. Much of this technical information is addressed in various certification programs or preparatory courses for health insurance specialists.

Along with all of the above, the health insurance worker needs to know the employer’s strategy for dealing with insurance related challenges. This often includes standards for re-billing claims with amended information within a given time period. Often, successful claim resolution relies on intimate knowledge of how the private health insurance company’s office, or the office of government programs, operate.