17 Medical Claims Examiner Interview Questions and Answers

When you’re sick or injured, you rely on your health insurance to help cover the cost of your medical care. But before your insurance company can process and pay your claim, it first has to be reviewed by a medical claims examiner.

Medical claims examiners are responsible for reviewing patient records to determine whether the services rendered are eligible for coverage under the patient’s insurance policy. They also calculate the amount of the reimbursement the provider will receive.

If you want to become a medical claims examiner, you’ll need to have strong analytical and communication skills. You’ll also need to be familiar with medical terminology and coding. During your job interview, you’ll be asked questions about your skills and experience. You’ll also be asked behavioral interview questions about how you handle difficult situations.

To help you prepare for your interview, we’ve compiled a list of sample medical claims examiner interview questions and answers.

Are you familiar with the Healthcare Claims Processing Standards?

The interviewer may ask this question to assess your knowledge of the standards that govern how medical claims are processed. The Healthcare Claims Processing Standards are a set of guidelines for processing insurance claims, and they’re published by the American Medical Association (AMA). If you have experience working with these standards, describe what you know about them in your answer.

Example: “I am familiar with the AMA’s Healthcare Claims Processing Standards. I worked as an insurance claims examiner at my last job, where we had to process all our claims according to these standards. We were required to check every claim for accuracy before submitting it to the insurance company. This was important because if we didn’t follow the standards, the insurance company could reject the claim.”

What are the most important qualities for a successful medical claims examiner?

Employers ask this question to learn more about your personality and how you would fit in with their team. They want someone who is organized, detail-oriented and able to work independently. When answering this question, try to highlight the skills that helped you succeed in previous roles.

Example: “I think one of the most important qualities for a medical claims examiner is attention to detail. I am always careful when entering data into the computer system and double-check all my work before submitting it. Another quality I have is communication. I like to keep my supervisors informed on what I’m working on and any challenges I may be facing. This helps them provide me with guidance or additional resources if needed.”

How do you stay organized when reviewing a large number of medical records?

The interviewer may ask you this question to assess your organizational skills and how well you can manage a large workload. Use your answer to highlight your ability to stay organized, prioritize tasks and meet deadlines.

Example: “I use several different software programs to help me stay organized when reviewing medical records. I find that using these programs helps me keep track of the documents I need to review and which ones I have already reviewed. This allows me to focus on the most important information in each record and ensures that I don’t miss anything. In addition, I also use my calendar to schedule appointments with patients so I know what time I will be working on each task.”

What is your process for ensuring the confidentiality of all patient information?

The interviewer may ask this question to assess your ability to handle confidential information. Use examples from past experiences where you’ve handled sensitive data and maintained confidentiality.

Example: “I always ensure that I’m the only person who has access to patient records, which is why I use password-protected software for my work. In my last role, I was working on a case when another employee came into my office to ask me a question about their own work. When they saw what I was doing, they asked if they could help with anything. I politely declined and told them I was almost done. They left, but returned five minutes later asking again. I explained that it was company policy to keep all patient information private unless we’re discussing it in front of other employees.”

Provide an example of a time when you had to deny a claim and explain your reasoning.

Interviewers may ask this question to learn more about your decision-making process and how you handle conflict. When answering, it can be helpful to explain the reasoning behind your denial and highlight any steps you took to help the patient or client in another way.

Example: “When I worked as a claims examiner for an insurance company, I had a client who was injured while on vacation. The client claimed that they were hurt when their hotel room fell apart around them. After investigating the claim, I found out that the client actually broke a piece of furniture themselves and then reported it as an accident. I explained my reasoning to the client and helped them find a new insurance provider.”

If you discovered a mistake in your previous claims assessments, how would you correct the error?

This question can help the interviewer determine how you handle mistakes and whether you have a process for correcting them. Use your answer to highlight your ability to self-correct, learn from your errors and improve your work performance.

Example: “If I discovered an error in my previous claims assessments, I would immediately contact the patient or their healthcare provider to correct the mistake. If it was a simple mistake that could be fixed with a quick phone call, I would do so right away. However, if there were more complex issues involved, such as missing information or conflicting details, I would first research the issue thoroughly to ensure I understood all of the facts before contacting the patient or provider.”

What would you do if you were unable to determine the eligibility of a patient for coverage after multiple assessments?

Interviewers may ask this question to assess your problem-solving skills and ability to work independently. In your answer, demonstrate that you can use critical thinking skills to solve problems and make decisions.

Example: “If I was unable to determine the eligibility of a patient for coverage after multiple assessments, I would first try to gather more information about the patient’s medical history. If I still couldn’t find an appropriate solution, I would consult my supervisor or another colleague with expertise in the field. This ensures that I am making the best decision possible while also maintaining the integrity of the company.”

How well do you perform under pressure and in high-stress environments?

Interviewers may ask this question to assess your ability to work in a fast-paced environment. They want to know that you can handle the pressure of working with tight deadlines and multiple tasks at once. In your answer, try to show that you are comfortable with high-pressure situations and have strategies for managing stress.

Example: “I thrive under pressure because it motivates me to get things done quickly. I find that when I’m feeling stressed or anxious about a deadline, I am more motivated to complete my work as efficiently as possible. In my last role, I was often tasked with completing large amounts of work within short timeframes. I found that I could meet these challenges by prioritizing my work and focusing on one task at a time.”

Do you have experience working with insurance companies in different states?

This question can help the interviewer determine if you have experience working with different insurance companies and how well you adapt to new environments. Use your answer to highlight any unique experiences you’ve had in this field, such as traveling for work or collaborating with a team of professionals from other states.

Example: “I worked for an insurance company that was based out of California but also provided services to clients in New York. I helped create processes that would allow us to provide quality service to both our California and New York clients while still maintaining compliance with state regulations. This experience taught me how important it is to understand the nuances of each state’s laws when working with insurance companies.”

When performing a claims assessment, what is the process for determining eligibility and calculating the amount of reimbursement?

This question is an opportunity to demonstrate your knowledge of the claims process and how you apply it in your daily work. When answering this question, provide a step-by-step overview of the claims assessment process and include examples from your experience that show your expertise.

Example: “When performing a claims assessment, I first review all documentation provided by the patient or provider. Next, I determine eligibility for reimbursement based on the type of claim and any applicable regulations. After determining eligibility, I calculate the amount of reimbursement using the appropriate formula or calculation method. Finally, I submit my findings to my supervisor for approval.”

We want to improve our claims assessment accuracy. What strategies would you recommend to improve our current process?

Interviewers may ask this question to gauge your problem-solving skills and ability to implement change. In your answer, explain how you would improve the current process by using your experience and knowledge of best practices in claims assessment accuracy.

Example: “I would recommend implementing a quality assurance program that includes regular audits of our assessments. This will allow us to ensure we’re following industry standards for claims processing and reduce any errors or inconsistencies in our work. I also think it’s important to have an open dialogue with my team about their concerns and ideas for improvement so we can develop new processes together.”

Describe your experience with using medical software to complete your job duties.

The interviewer may ask this question to learn more about your experience with medical software and how you use it in your daily job. Use your answer to describe the type of software you’ve used, what kind of tasks you completed using it and any skills you have that help you work with the software.

Example: “I’ve worked for my current employer for five years, and during that time I’ve learned a lot about the company’s proprietary software. The software is very user-friendly, so I don’t need much training when new employees join our team. In fact, I often train new employees on how to use the software because it’s easy to navigate once you understand its basic functions.”

What makes you an ideal candidate for this job?

Employers ask this question to learn more about your qualifications and how you can contribute to their company. Before your interview, make a list of all the skills and experiences that make you an ideal candidate for this role. Focus on highlighting your relevant work experience, education credentials and soft skills.

Example: “I am an ideal candidate for this job because I have five years of experience as a medical claims examiner. During my career, I’ve developed strong analytical and problem-solving skills. I also have excellent communication and interpersonal skills. These skills allow me to collaborate with other team members and patients. In addition, I’m highly organized and detail-oriented. This skill has helped me find errors in patient records and reduce insurance costs.”

Which medical fields do you have the most experience with?

This question can help the interviewer determine if your experience aligns with the job description. It also helps them understand what you’re passionate about and how much time you’ve spent in this field. When answering, be sure to mention any medical fields that are not listed in the job description but that you have experience with.

Example: “I have the most experience working as a medical claims examiner for orthopedic surgeons. I worked there for five years before moving to my current position at a pediatric hospital. However, I am still very familiar with the process of filing insurance claims for orthopedic procedures.”

What do you think is the most challenging part of being a medical claims examiner?

Interviewers may ask this question to see if you are aware of the challenges that come with this role. They want to know how prepared you are for these challenges and whether you have any strategies for overcoming them. In your answer, try to identify a challenge and explain what you would do to overcome it.

Example: “The most challenging part of being a medical claims examiner is having to deny claims. I understand that there are many reasons why claims get denied, but it’s still hard when patients call me upset because their claim was denied. To help with this situation, I always make sure to be as compassionate as possible when explaining why a claim was denied. I also offer advice on how they can resubmit the claim in order to increase their chances of getting approved.”

How often do you make mistakes when assessing claims?

This question can help the interviewer determine how much experience you have as a medical claims examiner. It also helps them understand your level of confidence and self-awareness. When answering this question, it can be helpful to mention a specific mistake you made in the past and what you learned from it.

Example: “I’ve only been working as a medical claims examiner for two years now, but I still make mistakes sometimes. However, I try my best to learn from these mistakes by researching more about the claim or asking questions when needed. In my previous role, I once misread a patient’s diagnosis and denied their claim because of it. After realizing my error, I researched the diagnosis further and found that it was actually covered under our insurance plan.”

There is a high volume of claims to assess and a deadline to meet. How do you stay focused?

This question can help an interviewer understand how you manage a high-pressure environment and whether your personality is suited to the role. Use examples from previous experience that show you are able to stay focused in a deadline-driven work environment.

Example: “I have worked in a fast-paced environment before, so I am used to working under pressure. In my last position, there were many deadlines each day, but I was always able to meet them because I learned to prioritize tasks and focus on one at a time. I also use organizational tools like task management software to keep track of what needs to be done.”