EDUCATION AND TRAININ

Training and entry requirements vary widely for health insurance specialists,
and the Occupational Outlook Handbook states that opportunities will be best
for those with a college degree. Academic programs should include coursework
(Table 1-1) in general education (e.g., anatomy and physiology, English composition,
oral communications, human relations, computer applications, and so on)


and health insurance specialist education (e.g., health information management,
medical terminology, pharmacology, coding and reimbursement, insurance processing,
and so on). The characteristics of a successful health insurance specialist
include an ability to work independently, a strong sense of ethics, attention
to detail, and the ability to think critically. The American Heritage Concise
Dictionary defines ethics as the principles of right or good conduct, and rules
that govern the conduct of members of a profession.

Student Internship
An internship benefits students and facilities that accept students for placement.
Students receive on-the-job experience prior to graduation, and the internship
assists them in obtaining permanent employment. Facilities benefit from the

Table 1-1 Training requirements for health insurance specialists

Anatomy and Physiology,
Medical Terminology,
Pharmacology, and
Pathophysiology
Knowledge of anatomic structures and physiological functioning of the body, medical terminology
and essentials of pharmacology are necessary to recognizing abnormal conditions (pathophysiology).
Fluency in the language of medicine and the ability to use a medical dictionary as a reference are
crucial skills.

Diagnosis and Procedure/
Service Coding
Understanding the rules, conventions, and applications of coding systems ensures proper selection of
diagnosis and procedure/service codes, which are reported on insurance claims for reimbursement
purposes.

EXAMPLE: Patient undergoes simple suture treatment of 3 cm facial laceration.
When referring to the CPT index, there is no listing for “Suture, facial
laceration.” There is, however, an instructional notation below the entry for
“Suture” that refers the coder to “Repair.” When “Repair” is referenced in
the index, the coder must then locate the subterms “Skin,” “Wound,” and
“Simple.” The code range in the index is reviewed, and the coder must refer
to the tabular section of the coding manual to select the correct code.

Verbal and Written
Communication
Health insurance specialists explain complex insurance concepts and regulations to patients and
must effectively communicate with providers regarding documentation of procedures and services (to
reduce coding and billing errors). Written communication skills are necessary when preparing effective

appeals for unpaid claims.
Critical Thinking Differentiating among technical descriptions of similar procedures requires critical thinking skills.
eXAMPLe: Patient is diagnosed with spondylosis, which is defined as any
condition of the spine. A code from category 721 of ICD would be assigned.
If the specialist read the diagnosis as spondylolysis, which is a defect of the
articulating portion of the vertebra, and assigned a code from ICD category
756 (if congenital) or 738 (if acquired), the coder would be in error.
Data Entry Federal regulations require electronic submission of most government claims, which means that health

insurance specialists need excellent keyboarding skills and basic finance and math skills. Because
insurance information screens with different titles often contain identical information, the health insurance

specialist must carefully and accurately enter data about patient care.
EXAMPLE: Primary and secondary insurance computer screens require entry
of similar information. Claims are rejected by insurance companies if data is
missing or erroneous.

Internet Access Online information sources provide access to medical references, insurance company manuals, and

procedure guidelines. The federal government posts changes to reimbursement methodologies and
other policies on Web sites. Internet forums allow health insurance specialists to network with other
professionals.

Table 1-1 Training requirements for health insurance specialists
opportunity to participate in and improve the formal education process. Quite
often, students who complete internships obtain employment at the internship
facility. The internship supervisor is the person to whom the student reports
at the site. Students are often required to submit a professional résumé to the
internship supervisor and schedule an interview prior to acceptance for placement.
While this process can be intimidating, students gain experience with the
interview process that is part of obtaining permanent employment. Students

should research résumé writing and utilize interview technique services available
from their school’s career services office. This office typically reviews résumés
and provides interview tips. (Some offices even videotape mock interviews
for students.)


The internship is on-the-job training even though it is unpaid, and students
should expect to provide proof of immunizations (available from a physician)
and possibly undergo a pre-employment physical examination and participate
in an orientation. In addition, because of the focus on privacy and security of
patient information, the facility will likely require students to sign a nondisclosure
agreement (to protect patient confidentiality), which is kept on file at the
school college and by the internship site.

During the internship, students are expected to report to work on time.
Students who cannot attend the internship on a particular day (or who arrive
late) should contact their internship supervisor or program faculty, whoever is
designated for that purpose. Students are also required to make up any lost time.
Because the internship is a simulated job experience, students are to be well
groomed and should dress professionally. Students should show interest in all
aspects of the experience, develop good working relationships with coworkers,
and react appropriately to criticism and direction. If any concerns arise during
the internship, students should discuss them with their internship supervisor
or program faculty.