Top 10 Questions for Medical Claims Examiner Interview

1. Explain the process of medical claims adjudication?

Medical claims adjudication is the process of reviewing and assessing medical claims to determine if they are valid and payable. It involves examining the claim form, verifying the patient’s eligibility, checking for errors or inconsistencies, and determining if the services rendered are medically necessary and appropriate.

• Review claim form for completeness and accuracy
• Verify patient eligibility for coverage
• Check for errors or inconsistencies in the claim
• Determine if the services rendered are medically necessary and appropriate
• Assign appropriate codes and modifiers
• Calculate the amount of reimbursement
• Review claim for potential fraud or abuse
• Communicate with providers and patients as needed

2. Describe the different types of medical claims fraud and how to detect them?

Types of Medical Claims Fraud

• Upcoding: Billing for a higher level of service than was actually provided
• Unbundling: Billing for multiple services that should be bundled together
• Duplicate billing: Billing for the same service multiple times
• Phantom billing: Billing for services that were never provided
• False diagnosis: Billing for a diagnosis that is not supported by the medical record

How to Detect Medical Claims Fraud

• Reviewing claims for unusual patterns or trends
• Comparing claims to the patient’s medical record
• Investigating providers with a history of fraud
• Using data analytics to identify potential fraud
• Educating providers and patients about fraud

3. What are the key components of a medical claim?

The key components of a medical claim include:

• Patient information (name, address, date of birth, etc.)
• Provider information (name, address, tax ID number, etc.)
• Procedure codes (CPT or HCPCS codes)
• Diagnosis codes (ICD-10 codes)
• Dates of service
• Amount charged
• Place of service
• Type of insurance

4. What are the most common reasons for medical claims to be denied?

The most common reasons for medical claims to be denied include:

• Incomplete or inaccurate information
• Lack of medical necessity
• Services not covered by insurance
• Duplicate billing
• Fraud or abuse

5. How do you handle denied claims?

When a medical claim is denied, I first review the denial reason and determine if it is valid. If the denial is valid, I will work with the provider to correct the errors and resubmit the claim. If the denial is not valid, I will appeal the decision with the insurance company.

6. What are your strengths and weaknesses as a Medical Claims Examiner?

Strengths

• Strong knowledge of medical terminology and coding
• Excellent attention to detail
• Ability to work independently and as part of a team
• Experience with medical claims processing software
• Strong communication and interpersonal skills

Weaknesses

• Limited experience with certain types of medical claims (e.g., workers’ compensation)
• Need to improve efficiency in processing claims

7. Why are you interested in this position?

I am interested in this position because I am passionate about helping people and I believe that my skills and experience would be a valuable asset to your team. I am eager to learn more about the medical claims process and I am confident that I can make a positive contribution to your company.

8. What are your salary expectations?

My salary expectations are commensurate with my experience and qualifications. I am confident that I can negotiate a salary that is fair and equitable for both parties.

9. Are you available to work overtime?

Yes, I am available to work overtime as needed. I understand that the workload can fluctuate at times, and I am willing to do my part to ensure that all claims are processed timely and accurately.

10. Do you have any questions for me?

Yes, I have a few questions for you:

• What is the company’s culture like?
• What are the opportunities for advancement?
• What is the company’s policy on work-life balance?

Medical Claims Examiners are the backbone of the healthcare industry. They ensure that medical claims are processed accurately and efficiently, so that patients receive the benefits they are entitled to.

1. Review and process medical claims

This is the core responsibility of a Medical Claims Examiner. They must review medical claims to ensure that they are complete and accurate. They must also verify that the services billed for are medically necessary and that the charges are reasonable.

• Analyze medical records to determine the medical necessity of services
• Verify that the charges billed are reasonable and in accordance with insurance policies

2. Communicate with healthcare providers and patients

Medical Claims Examiners often need to communicate with healthcare providers and patients to clarify information on medical claims. They must be able to communicate effectively and professionally, both in writing and over the phone.

• Request additional information from healthcare providers to support medical claims
• Explain claim denials or payment decisions to patients

3. Investigate and resolve claims issues

Medical Claims Examiners may need to investigate and resolve claims issues. This may involve reviewing medical records, conducting interviews, and making determinations on coverage.

• Investigate claims that are suspected of being fraudulent or abusive
• Resolve disputes between healthcare providers and patients over claims payments

4. Stay up-to-date on healthcare regulations

Healthcare regulations are constantly changing. Medical Claims Examiners must stay up-to-date on these changes to ensure that they are processing claims in accordance with the latest requirements.

• Attend training and workshops to learn about new healthcare regulations
• Review publications and online resources to stay informed about industry updates

Preparing for a Medical Claims Examiner interview can be daunting, but with the right preparation, you can increase your chances of success. Here are some tips to help you ace your interview:

1. Research the company and the position

Before you go into your interview, take some time to research the company and the position you are applying for. This will help you understand the company’s culture and values, and it will also give you a better idea of what the job entails.

• Visit the company’s website to learn about their mission, values, and products or services.
• Read online reviews of the company to get an idea of what it’s like to work there.

2. Practice answering common interview questions

There are a number of common interview questions that you are likely to be asked, such as “Tell me about yourself” and “Why are you interested in this position?” It is helpful to practice answering these questions in advance so that you can deliver your answers confidently and concisely.

• Use the STAR method to answer behavioral questions.
• Example Outline:
• Situation: Briefly describe the situation you were in.
• Task: Explain the task you were responsible for.
• Action: Describe the specific actions you took.
• Result: Quantify the results of your efforts, if possible.

3. Dress professionally and arrive on time

First impressions matter, so it is important to dress professionally and arrive on time for your interview. This shows the interviewer that you are respectful of their time and that you are serious about the position.

• Wear a suit or business casual attire.
• Arrive at the interview location 15 minutes early.

4. Be yourself

The most important thing is to be yourself during your interview. The interviewer wants to get to know the real you, so don’t try to be someone you’re not. Just relax, be confident, and let your personality shine through.

• Be honest and authentic in your answers.
• Show the interviewer your passion for the healthcare industry.