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  • Health insurance specialist is a well-qualified professional with a detailed knowledge of health insurance procedures
  • They can manage medical coding procedures and check coding for accuracy
  • Specialist post medical services charges and billings
  • They can manage patient records in a number of settings


Health insurance specialists play an important role in the operation of health Insurance across the US. They work for the government as well as private medical care businesses. They work in professional offices, clinics, and hospitals, and their work contributes to overall operations and patient care. Their skills and knowledge include a detailed understanding of the health insurance processes, but they also have strong backgrounds in communications and computer-based office functions.

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Public Sector versus Private Sector


The role of the health insurance specialist may change remarkably with whether they work for a private provider or the state and federal governments.

In the public sector, there is a greater emphasis on managing the huge system, a vast network of contractor, business, suppliers, and specialty contractors.

Health insurance specialists can get deeply involved in high-level operations in many of theses government processes. With oversight responsibilities, the public sector offers more opportunities to shape events and policies.

  • Health insurance specialists at the CMS develop and interpret policy for health care financing. This work affects the exchange of tens of billions of dollars in federal funds. They help evaluate system performance and identify areas for improvements
  • Health insurance specialists in the Obamacare Marketplace provide technical support as well as direct advice and assistance to applicants.They can research and resolve issues of policy that can interfere with orderly registration.
  • Health insurance specialists in Marketing are particularly important to the volume driven goals of the Affordable Care Act. With the individual mandate, the ACS sets a strong incentive for coverage by every eligible person.
  • Health insurance specialists in support functions include those at local and regional offices that work with one or more state governments. They must have extensive knowledge of the variations that come with state and local rules and policies.

Federal Oversight


Health insurance specialists review and assess state Medicaid programs to ensure that they meet Federal regulations. The specialists look at eligibility, payment practices, and issues of fairness. Staff provides advice about the law, regulations, and policy in such issue areas as eligibility, coverage, and payment.

In contract situations, the specialists evaluate contract performance of the firms that work with Medicaid. They consider federal rules, the terms of the contracts, and any applicable federal laws and regulations.

  • Medicare Advantage consists of private plans. The CMS reviews the plans and assesses the strength and level of completion of the networks. When the network is development or not completely built-out, the CMS requires an additional agreement by the sponsors to pay for any needed coverage at the ordinary rate paid by Original Medicare.
  • Medicare analysis is another area for focus by health insurance specialists. They examine Medicare policy, look at trends in the private sector, study the private insurance markets, and they take part in on-site inspections and evaluations.
  • Specialists can analyze Medicare Advantage plans for consistency with federal rules and requirements. They support the CMS assessment of the adequacy if the terms and resources in the plan network.
  • Medicaid policies are an important area for the health insurance specialists. This situation exists in large part to the fact that states each develop operating rules and procedures. To work with more than one state government requires an extensive understanding of local situations, rules, and procedures.

Selecting a Health Insurance Plan

A health Insurance specialist can assist consumers when investigating and selecting health insurance plans. This is one of the primary roles of the health Insurance Specialist. They understand the working of health insurance and can point the consumer towards facts that help them understand the benefits of one approach over another.

Selecting with Expertise


Many consumers realize that they do not know enough about health insurance and they take steps to improve their knowledge. One step is to consult with experts in the field of health insurance. These experts include insurance agents, insurance brokers, and health insurance specialists.

Health insurance brokers and agents each have sales and profits in their agendas. They as a group have been an able resource; their unique knowledge of markets and trends was particularly useful during the rollout of Obamacare in 2014.

Claims Processing

Claims processing is at the heart of federal regulations by CMS, and many medical care businesses. This situation reflects the importance of health insurance claims as a means of payment.

Health insurance specialists can manage the claims process. They can review patient records and ensure accuracy when billing.

The latest practices are important for claims billing, Medicare and other large insurers have rules and procedures that vary from time to time. These changes cause delays and rejections.

Communication is Important


Health insurance specialist must have knowledge of medical procedures and terminology. They handle communications by several means including electronic transmission and email. Clear communications can be difficult in medical terms and technical verbiage.

It is the task of the health insurance specialist to provide effective communications on patient care, records, claims, and billing. The self-employed may seek advice from a health insurance specialist. They can take advantage of a special deduction for self-employed persons.

Medical Records

Medical records management is one of the tasks most valued by medical care providers. The records are critical to many of the objectives of medical care. They are essential for accurate coding and claims processing.

Managing medical records is an essential part of the tasks of the health insurance specialists in government and industry. It is particularly important to medical care facilities that must submit accurate and timely claims.

Health insurance specialists are critical in:

  • Protecting the patient against accidental injury and misdiagnosis.
  • Protecting the provider against internal oversights and treatment errors.
  • Ensuring accuracy in treatments records and related patient information.

Patient follow-up

Doctors may leave some part of an examination or procedure in their treatment notes. These valuable pieces of information are part of the record that Specialists have been trained to protect. When following up on patient treatment records, health insurance specialists will take care that the entire record is kept intact.

Health Insurance Specialists Have Important Roles


Health insurance specialists play some important roles in health insurance. They can help consumers select the best policy for their individual or family situation. Relying on the expertise of health insurance specialists is one good way to find value.

Comparison shopping can get the high-value results that one expects when using a professional. Enter your zip code below to compare free health insurance quotes online now!

[su_spoiler title=”References:” icon=”caret-square” style=”fancy” open=”yes”]

  1. https://www.healthcare.gov/glossary/specialist/
  2. https://www.cms.gov/About-CMS/Career-Information/CareersatCMS/Positions.html
  3. https://www.medicaid.gov/medicaid/program-information/downloads/accomplishments-report.pdf
  4. https://www.cms.gov/cciio/programs-and-initiatives/health-insurance-marketplaces/qhp.html
  5. http://obamacarefacts.com/insurance-exchange/how-to-buy-health-insurance/
  6. http://obamacarefacts.com/essential-health-benefits/
  7. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf
  8. http://obamacarefacts.com/self-employed-health-insurance/
  9. http://obamacarefacts.com/2014/10/06/electronic-health-records-doctors/
  10. https://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Downloads/Understanding-the-Marketplace-Professional-Data-on-Webinar-Course-Developers.pdf
  11. http://obamacarefacts.com/2015/12/04/hhs-2016-marketplace-facts-sheet-on-obamacare/