Claim auditor vs claim specialist

The differences between claim auditors and claim specialists can be seen in a few details. Each job has different responsibilities and duties. Additionally, a claim auditor has an average salary of $46,802, which is higher than the $43,164 average annual salary of a claim specialist.

The top three skills for a claim auditor include medical terminology, medicaid and patients. The most important skills for a claim specialist are customer service, litigation, and patients.

Claim auditor vs claim specialist overview

	Claim Auditor	Claim Specialist
Yearly salary	$46,802	$43,164
Hourly rate	$22.50	$20.75
Growth rate	6%	-6%
Number of jobs	22,068	29,505
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 45%	Bachelor's Degree, 54%
Average age	44	44
Years of experience	-	6

What does a claim auditor do?

A claims auditor is primarily in charge of processing and auditing claims in companies and other institutions, ensuring accuracy and smooth workflow. Their responsibilities include coordinating with staff to gather the necessary data, liaising with clients to identify their needs, assessing the eligibility and validity of claims, verifying payments, and maintaining records of all transactions. Furthermore, as a claims auditor, it is essential to ensure that all claims and payments are carried out in adherence to the company's policies and regulations.

What does a claim specialist do?

A claims specialist is responsible for processing insurance claims, reviewing insurance coverage, and analyzing claims cases. Claims specialists' duties include negotiating claims settlements, validating claims to prevent fraud, creating court testimonies as needed, developing claim review plans, and checking necessary documents and related resolve claims. A claims specialist must have strong analytical and critical-thinking skills to authorize claim payment and investigate complex and unusual claims. Claims specialists should also have extensive knowledge of the insurance processes to handle various cases, following legal policies and regulatory procedures.

Claim auditor vs claim specialist salary

Claim auditors and claim specialists have different pay scales, as shown below.

	Claim Auditor	Claim Specialist
Average salary	$46,802	$43,164
Salary range	Between $34,000 And $64,000	Between $27,000 And $67,000
Highest paying City	San Francisco, CA	Newark, NJ
Highest paying state	Washington	New Jersey
Best paying company	Berkshire Hathaway	W. R. Berkley
Best paying industry	Insurance	Insurance

Differences between claim auditor and claim specialist education

There are a few differences between a claim auditor and a claim specialist in terms of educational background:

	Claim Auditor	Claim Specialist
Most common degree	Bachelor's Degree, 45%	Bachelor's Degree, 54%
Most common major	Business	Business
Most common college	University of Pennsylvania	Stanford University

Claim auditor vs claim specialist demographics

Here are the differences between claim auditors' and claim specialists' demographics:

	Claim Auditor	Claim Specialist
Average age	44	44
Gender ratio	Male, 23.9% Female, 76.1%	Male, 31.0% Female, 69.0%
Race ratio	Black or African American, 8.6% Unknown, 4.0% Hispanic or Latino, 10.9% Asian, 12.2% White, 63.9% American Indian and Alaska Native, 0.5%	Black or African American, 11.4% Unknown, 4.4% Hispanic or Latino, 16.5% Asian, 5.1% White, 62.1% American Indian and Alaska Native, 0.5%
LGBT Percentage	7%	10%

Differences between claim auditor and claim specialist duties and responsibilities

Claim auditor example responsibilities.

Work with department analyst to create measurement tools and methods for communicating results and managing QA analysis in compiling/reporting results.
Bill and prepare claims appeals for Medicare, Medicaid, and private payers.
Review medical records and charges of hospital, ambulatory surgery and physician bills to verify CPT, ICD-9 and HCPCS codes.
Research and determine accuracy of ICD-9 and CPT codes on CMS 1500 and UB 92 claims forms on a daily basis.
Evaluate DRG grouping and pricing information.
Audit all claims types for a Medicare HMO plan.

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Claim specialist example responsibilities.

Assist in the streamlining of EDI process to manage workflow of EDI claims.
Manage claims on desk, route/queues, and ECHS within specify turn-around-time parameters.
Manage claims, route/queues, and ECHS, within specify turn- around time parameters.
Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
Upgrade CPT-4 and ICD-9 coding procedures, staying in step with many manage care plans changing reimbursement schedules.
Manage expedition of appeals via problem solving and collaboration with other departments.

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Claim auditor vs claim specialist skills

Common claim auditor skills

Medical Terminology, 9%
Medicaid, 8%
Patients, 6%
HCPCS, 5%
CMS, 5%
Audit Findings, 5%

Common claim specialist skills

Customer Service, 19%
Litigation, 7%
Patients, 5%
Claims Handling, 4%
Quality Standards, 4%
Excellent Organizational, 4%

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Updated January 8, 2025

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