Top 30 Medical Claims Examiner Interview Questions and Answers [Updated 2025]
Andre Mendes
•
March 30, 2025
Preparing for a Medical Claims Examiner interview can be daunting, but with the right guidance, you can confidently showcase your expertise. This blog post brings together the most common interview questions for this crucial role, providing you with example answers and effective tips to help you stand out. Dive in to enhance your preparation and approach your interview with assurance and clarity.
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List of Medical Claims Examiner Interview Questions
Behavioral Interview Questions
Can you provide an example of how you worked effectively within a team to achieve a common goal?
How to Answer
- 1
Choose a specific team project with a clear outcome
- 2
Describe your role and contributions to the team
- 3
Highlight collaboration and communication methods used
- 4
Emphasize the result achieved and its impact
- 5
Reflect briefly on what you learned from the experience
Example Answers
In my previous role, our team was tasked with reducing claim processing time. I coordinated meetings to improve communication, contributed to the workflow analysis, and proposed a new tracking system. As a result, we reduced processing time by 20%, which improved overall efficiency.
Describe a time when your attention to detail prevented an error in your work.
How to Answer
- 1
Choose a specific example from your past work experience.
- 2
Explain the context and the potential error that was avoided.
- 3
Highlight the specific actions you took that demonstrated your attention to detail.
- 4
Mention the outcome and how it benefited the team or the organization.
- 5
Keep your answer concise, focusing on clear and relevant details.
Example Answers
In my previous role as a medical claims processor, I double-checked a submission for a major health service. I noticed a discrepancy in the diagnosis codes, which if processed, would have resulted in a denial. I corrected the codes before submission, ensuring timely payment for the provider.
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Tell me about a time when you had to prioritize multiple tasks with tight deadlines. How did you handle it?
How to Answer
- 1
Choose a specific example from your past experience.
- 2
Explain the tasks you had to prioritize and why they were urgent.
- 3
Discuss the strategies you used to manage your time effectively.
- 4
Highlight the outcome and what you learned from the experience.
- 5
Keep your answer focused and relevant to the role of a Medical Claims Examiner.
Example Answers
In my previous role, I was responsible for processing medical claims while also handling patient inquiries. When a system outage occurred, I prioritized the claims that were close to their deadlines. I created a checklist to track each claim's status and worked efficiently to process them first, staying late to ensure completion. Ultimately, we met all deadlines, and it taught me the importance of organization under pressure.
Give an example of a complex problem you faced and how you went about solving it.
How to Answer
- 1
Identify a specific complex problem relevant to medical claims.
- 2
Explain your thought process and the steps you took to address the issue.
- 3
Highlight any collaboration with team members or departments.
- 4
Discuss the outcome and what you learned from the experience.
- 5
Keep your answer focused and concise to maintain engagement.
Example Answers
In my previous role, I encountered a complex issue where a large batch of claims was denied due to incorrect coding. I gathered a team to review the claims and trac them back to original submissions. By identifying patterns, we corrected the coding errors and implemented additional training for submitters. As a result, the claims approval rate increased by 30%.
Describe a situation where you had to explain a complex idea to someone who was not familiar with the topic.
How to Answer
- 1
Choose a specific example from your experience.
- 2
Focus on the complexity of the idea and the audience's lack of knowledge.
- 3
Describe the method you used to simplify the explanation.
- 4
Highlight any tools or analogies that helped convey your message.
- 5
Conclude with the outcome of your explanation and feedback received.
Example Answers
In my previous role at an insurance company, I had to explain the appeal process for denied claims to a policyholder who was unfamiliar with it. I used a step-by-step approach, explaining each stage in simple language and comparing it to a basic 'build-it yourself' project. After my explanation, the client thanked me for clarifying the process and felt more confident about submitting an appeal.
Tell me about a time when you had a conflict with a colleague and how you resolved it.
How to Answer
- 1
Choose a specific conflict that showcases your conflict resolution skills.
- 2
Focus on your role in the conflict and how you contributed to the resolution.
- 3
Emphasize communication and collaboration in resolving the issue.
- 4
Highlight the outcome and what you learned from the experience.
- 5
Keep the tone positive and solution-focused.
Example Answers
At my previous job, I had a disagreement with a colleague over the interpretation of a medical policy. I approached them directly and asked to discuss our viewpoints. We agreed to review the policy together and brought in our supervisor for clarification. By the end, we resolved our differences, and I learned the importance of direct communication.
Situational Interview Questions
Imagine several urgent claims have just come in. How would you manage your workload?
How to Answer
- 1
Prioritize claims based on urgency and complexity
- 2
Use a checklist to track each claim's status
- 3
Communicate with your team to delegate tasks if possible
- 4
Stay organized using digital tools or spreadsheets
- 5
Set clear deadlines for each claim to ensure timely processing
Example Answers
I would first assess the claims to identify the most urgent ones and prioritize them. Then, I'd create a checklist for each claim to track their progress. If the workload is too high, I'd delegate some less urgent tasks to colleagues while ensuring communication.
You received a claim that appears fraudulent. How would you handle it?
How to Answer
- 1
Verify the details of the claim against your system records.
- 2
Gather any evidence that supports your suspicion of fraud.
- 3
Consult with a supervisor or the fraud department for further instructions.
- 4
Document your findings and actions taken regarding the claim.
- 5
Follow company procedures for reporting and handling fraudulent claims.
Example Answers
I would first verify the claim details in our system to check for discrepancies. If I find anything suspicious, I would document my findings and consult with my supervisor and the fraud department to determine the next steps.
Don't Just Read Medical Claims Examiner Questions - Practice Answering Them!
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You have a backlog of claims to process, each with a different due date. How would you prioritize them?
How to Answer
- 1
Identify the claims with the nearest due dates and address those first.
- 2
Determine the complexity of each claim to ensure efficiency.
- 3
Communicate with your team or management if you feel overwhelmed by the backlog.
- 4
Utilize any available tools or software for tracking deadlines and prioritization.
- 5
Consider the financial impact of claims and prioritize those with higher stakes for the company.
Example Answers
I would first list all the claims by their due dates and start processing the ones that are due soonest. Next, I would evaluate the complexity of each claim to allocate my time effectively. If I feel overwhelmed, I would reach out to my supervisor for support.
How would you handle a situation where a claimant is disputing the decision on their claim?
How to Answer
- 1
Listen actively to the claimant's concerns without interrupting.
- 2
Remain calm and empathetic, showing understanding of their frustration.
- 3
Explain the decision clearly, citing specific policies or guidelines.
- 4
Offer to review the claim again if new information has emerged.
- 5
Document the conversation and follow up with the claimant as promised.
Example Answers
Firstly, I would listen carefully to the claimant's issues and show empathy towards their situation. Then, I would explain the reasons for the claim denial based on our policies, ensuring they understand the process. If they have new information, I would gladly review the claim again and keep them updated on the outcome.
A claim you are working on is missing key information. What steps would you take to obtain the needed information?
How to Answer
- 1
Identify the specific missing information needed to process the claim.
- 2
Contact the claimant or provider directly to request the missing information.
- 3
Review any prior communications or documentation for clues.
- 4
Set a deadline for when the information is needed to keep the process on track.
- 5
Document all efforts made to obtain the information for future reference.
Example Answers
First, I would identify exactly what information is missing from the claim. Then, I would reach out to the claimant or provider to request that specific information. I would keep track of when I contacted them and set a deadline for follow-up.
A new regulation has been introduced that affects how you process claims. How would you adapt your workflow?
How to Answer
- 1
Review the new regulation thoroughly to understand its impact on claims processing.
- 2
Update your processing checklist or procedures to incorporate the new requirements.
- 3
Communicate changes to your team and ensure everyone understands the new workflow.
- 4
Seek feedback after implementation to identify any issues and adjust as necessary.
- 5
Stay informed about future regulations to continually improve your workflow.
Example Answers
I would start by thoroughly reviewing the new regulation to understand its specific requirements. Next, I would update our existing claims processing checklist to reflect these changes. It’s critical to then communicate these updates to my team, ensuring everyone is on the same page. We would also monitor the workflow after implementation for any challenges and adapt as needed.
How would you explain a claim denial to a policyholder who doesn't have much knowledge about insurance?
How to Answer
- 1
Start with empathy for the policyholder's situation.
- 2
Use simple and clear language without jargon.
- 3
Explain the reason for the denial directly and simply.
- 4
Provide examples or analogies to make the reason relatable.
- 5
Offer reassurance and explain next steps if they want to appeal.
Example Answers
I understand that getting a claim denied can be frustrating. In this case, the denial happened because the procedure wasn't covered under the policy. Think of it like a warranty that only covers certain types of repairs. You can appeal this decision if you believe it should be covered.
You notice a discrepancy in the data you're reviewing for a claim. What actions do you take?
How to Answer
- 1
Verify the discrepancy by checking the data against original documents.
- 2
Document the discrepancy clearly with details of what is incorrect.
- 3
Communicate with relevant stakeholders to gather more information.
- 4
Follow company protocols for handling discrepancies in claims.
- 5
Take corrective action based on findings and ensure proper resolution.
Example Answers
I first verify the discrepancy by cross-referencing the data with the original claim documents. Then, I document the specific issues I've found. After that, I reach out to the relevant parties to clarify the information and follow the company's protocol to resolve the discrepancy.
New claims processing software has been introduced. How would you go about learning it?
How to Answer
- 1
Review any provided training materials and documentation thoroughly
- 2
Schedule a meeting with a knowledgeable colleague or supervisor to discuss the software
- 3
Practice using the software in a test environment if available
- 4
Take notes on key features and functionalities as you learn
- 5
Participate in any available training sessions or webinars offered by the company
Example Answers
I would start by reviewing the training materials provided and take notes on the key features. Then, I would set up a time with a coworker who is experienced in the new software to run through it together. Finally, I would practice using the software in a test setup to become more comfortable with it.
How would you decide when to consult with a medical professional for a claim evaluation?
How to Answer
- 1
Assess the complexity of the medical condition involved in the claim
- 2
Evaluate if there is conflicting information in the documentation
- 3
Consider the need for clarification on medical terminology or procedures
- 4
Determine if the claim involves treatments not commonly understood
- 5
Follow company protocols for consultation to ensure compliance
Example Answers
I would consult a medical professional if the claim involves a complex diagnosis that requires specialized knowledge or if the documentation presents conflicting details about the patient's treatment.
Don't Just Read Medical Claims Examiner Questions - Practice Answering Them!
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How would you handle a situation where a colleague asks for information about a claim that they don’t have authorization to access?
How to Answer
- 1
Acknowledge the request politely
- 2
Explain the importance of confidentiality
- 3
Suggest ways they can get the information through proper channels
- 4
Offer to help them understand the authorization process
- 5
Maintain professionalism and avoid gossip
Example Answers
I appreciate your interest in the claim, but I can't share any details without proper authorization. It's important to keep our patient information confidential. You might want to check with your supervisor about accessing the necessary permissions.
Describe how you would collaborate with a colleague on a challenging claim review.
How to Answer
- 1
Initiate open communication with your colleague to discuss the claim details.
- 2
Share all relevant information, documents, and insights about the claim.
- 3
Listen to your colleague's perspective and consider their experience.
- 4
Develop a joint action plan to address the claim's challenges.
- 5
Follow up regularly to ensure both parties are aligned and making progress.
Example Answers
In tackling a challenging claim review, I would first reach out to my colleague to set up a time to discuss the specifics of the claim. I would share all relevant documentation and my observations, while also inviting them to share their insights. Together, we could create an action plan to address any issues and agree on timelines for follow-up.
How would you handle a situation where there is insufficient documentation to make a clear claim decision?
How to Answer
- 1
Review all available documentation thoroughly before making a decision.
- 2
Reach out to the provider or claimant for additional information or clarification.
- 3
Document all communications and your reasoning for transparency.
- 4
Consider referring the case to a supervisor if further expertise is needed.
- 5
Use company protocols to ensure compliance and standard procedures.
Example Answers
I would first review all the provided documentation to see if there is any information I might have overlooked. If it’s still insufficient, I would contact the provider for clarification and ask for any missing documents. I’d make sure to document the entire process and my communications for reference.
You've identified inefficiencies in the current claims processing system. What steps would you take to address them?
How to Answer
- 1
Analyze the current workflow to pinpoint specific inefficiencies.
- 2
Gather data on claims processing time and error rates.
- 3
Collaborate with colleagues to brainstorm potential solutions.
- 4
Implement a pilot program to test changes on a small scale.
- 5
Monitor results and adjust processes based on feedback.
Example Answers
First, I would analyze the current claims process to identify bottlenecks. Next, I'd collect data on processing times to understand where the delays occur. Then, I would involve my team in suggesting improvements, and we could implement a pilot program with the best ideas. Finally, I'd measure the impact of these changes to ensure they work effectively.
How would you stay informed about changes in medical billing and insurance regulations?
How to Answer
- 1
Subscribe to reputable medical billing blogs and newsletters.
- 2
Join professional organizations related to medical billing.
- 3
Attend webinars and conferences focused on healthcare regulations.
- 4
Follow relevant government agencies and industry leaders on social media.
- 5
Participate in online forums and discussion groups for medical claims examiners.
Example Answers
I subscribe to several medical billing newsletters and follow the American Health Information Management Association for updates.
Technical Interview Questions
What are some key medical terms you should know as a Medical Claims Examiner?
How to Answer
- 1
Focus on common medical billing codes like CPT and ICD.
- 2
Mention terminology related to insurance plans and coverage.
- 3
Include terms related to medical procedures and services.
- 4
Discuss the importance of healthcare regulations and compliance terms.
- 5
Highlight the need for understanding patient care documentation.
Example Answers
As a Medical Claims Examiner, I find it essential to know CPT codes, which detail specific medical procedures, and ICD codes for diagnoses. Terms like copayment and deductible are also crucial for understanding insurance coverage.
Can you walk me through the process of evaluating a medical insurance claim?
How to Answer
- 1
Begin by reviewing the claim form for completeness and accuracy
- 2
Verify the patient's insurance eligibility and coverage
- 3
Examine the medical documentation provided for relevance and necessity
- 4
Assess the billed services against current policy guidelines and fee schedules
- 5
Make a determination on payment or denial based on your findings
Example Answers
To evaluate a medical insurance claim, I first review the claim form to ensure it's complete and accurate. Then, I verify the patient's insurance eligibility and coverage to confirm they're entitled to the services. Next, I examine the medical documentation for relevance and necessity, ensuring it aligns with policy guidelines before determining payment or issuing a denial.
Don't Just Read Medical Claims Examiner Questions - Practice Answering Them!
Reading helps, but actual practice is what gets you hired. Our AI feedback system helps you improve your Medical Claims Examiner interview answers in real-time.
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Explain the difference between ICD-10 and CPT coding systems.
How to Answer
- 1
ICD-10 codes are used to describe diagnoses and diseases.
- 2
CPT codes are used for describing medical procedures and services.
- 3
ICD-10 codes are maintained by the World Health Organization.
- 4
CPT codes are maintained by the American Medical Association.
- 5
Explain the importance of both systems in medical billing and coding.
Example Answers
ICD-10 codes identify the patient's medical condition, such as a diagnosis of diabetes. In contrast, CPT codes document the procedures performed, like an office visit or a surgery.
What regulations must a Medical Claims Examiner be aware of when processing claims?
How to Answer
- 1
Understand HIPAA regulations to protect patient privacy and data.
- 2
Familiarize yourself with Medicare and Medicaid guidelines for claim approval.
- 3
Stay updated on state-specific laws that impact claim processing.
- 4
Know the National Correct Coding Initiative (NCCI) guidelines to avoid billing errors.
- 5
Learn about the False Claims Act to ensure compliance and prevent fraud.
Example Answers
A Medical Claims Examiner must be well-versed in HIPAA regulations to ensure patient confidentiality. Additionally, they should know Medicare and Medicaid guidelines, as these programs have specific rules that affect claim processing.
What software tools do you use for claims processing, and how proficient are you with them?
How to Answer
- 1
Identify key software tools relevant to claims processing, like claims management systems or billing software.
- 2
Be specific about your level of proficiency, such as beginner, intermediate, or expert.
- 3
Mention any certifications or training you have related to the software.
- 4
Share examples of how you used these tools in previous jobs to streamline processes or improve accuracy.
- 5
Express your willingness to learn new software if needed.
Example Answers
I primarily use XCLAIM for claims processing, and I consider myself an expert since I've used it for over three years. I completed a training course on it, which helped me in optimizing claims submission and tracking.
How do you use data analysis in your role as a Medical Claims Examiner?
How to Answer
- 1
Highlight specific tools or software you use for data analysis.
- 2
Mention how you identify trends in claims data.
- 3
Provide an example of resolving a claim issue using data analysis.
- 4
Discuss the importance of accuracy and compliance in data reporting.
- 5
Explain how data analysis impacts decision-making in claims processing.
Example Answers
In my role as a Medical Claims Examiner, I use Excel to analyze claims data by tracking trends in claim denials, which helps me identify common issues and address them proactively. For instance, I noticed a spike in denials related to coding errors, so I worked with our coding department to conduct a training session.
What factors do you consider when adjudicating a medical claim?
How to Answer
- 1
Review the patient's policy to ensure coverage for the service.
- 2
Check for medical necessity and appropriateness based on clinical guidelines.
- 3
Verify the provider's credentials and network status.
- 4
Ensure all required documentation and claims forms are complete and accurate.
- 5
Look for any potential fraud indicators or discrepancies in the claim.
Example Answers
When adjudicating a medical claim, I first check the patient's policy to confirm that the service is covered. I also assess the medical necessity of the procedure by referring to clinical guidelines. Additionally, I ensure that the provider is in-network and their credentials are valid. It's crucial to have all necessary documentation in place to avoid delays.
How do you ensure that you are interpreting insurance policies correctly when examining claims?
How to Answer
- 1
Review the insurance policy in detail, focusing on coverage limits and exclusions.
- 2
Cross-reference the claim with relevant policy clauses to confirm alignment.
- 3
Stay updated on industry standards and changes in regulations affecting policies.
- 4
Use checklists to ensure all necessary criteria are met while reviewing claims.
- 5
Consult with colleagues or supervisors when uncertain about an interpretation.
Example Answers
I begin by carefully reviewing the insurance policy to understand the specific coverage details. I then cross-check the claim against these details, making sure the claim meets all required policy conditions.
What are common billing errors you have encountered, and how do you identify them?
How to Answer
- 1
Identify specific types of errors like coding mistakes or duplicate claims
- 2
Explain the tools or methods you use to identify these errors
- 3
Highlight the importance of attention to detail in your role
- 4
Discuss how you stay updated on coding changes and regulations
- 5
Mention any experience with audit processes or claim reviews
Example Answers
In my experience, common billing errors include incorrect coding, particularly with CPT and ICD-10 codes, and duplicate submissions. I identify these errors by using software that flags inconsistencies and by cross-referencing claims with patient records.
Medical Claims Examiner Position Details
Salary Information
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Ace Your Next Interview!
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Ace Your Next Interview!
Practice with AI feedback & get hired faster
Personalized feedback
Used by hundreds of successful candidates