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Claim processor vs claims representative

The differences between claim processors and claims representatives can be seen in a few details. Each job has different responsibilities and duties. It typically takes 4-6 years to become both a claim processor and a claims representative. Additionally, a claim processor has an average salary of $41,201, which is higher than the $38,796 average annual salary of a claims representative.

The top three skills for a claim processor include customer service, data entry and medical terminology. The most important skills for a claims representative are customer service, quality standards, and policy coverage.

Claim processor vs claims representative overview

Claim ProcessorClaims Representative
Yearly salary$41,201$38,796
Hourly rate$19.81$18.65
Growth rate-6%-6%
Number of jobs11,54218,565
Job satisfaction--
Most common degreeBachelor's Degree, 43%Bachelor's Degree, 62%
Average age4444
Years of experience66

What does a claim processor do?

A Claims Processor is responsible for processing and verifying insurance claims, in adherence to the policies, laws, and regulations of the company involved. Aside from examining its authenticity, they must also oversee new policies and recommend modifications should it be needed. Moreover, it is also the task of the Claims Processor to prepare the necessary documents and guidelines for the policyholder, process reimbursements upon approval, provide answers to inquiries, and report issues and updates to the management.

What does a claims representative do?

A Claims Representative is an agent who works for insurance companies in order to investigate and settle claims. The agent acts as an intermediary between customers and insurance companies by evaluating the customers' facts surrounding claims and determining whether the loss is covered or should be compensated. Such a role is important because an agent makes sure that no fraud claims are being paid out. It is also highlighted that an agent works in compliance with state regulations.

Claim processor vs claims representative salary

Claim processors and claims representatives have different pay scales, as shown below.

Claim ProcessorClaims Representative
Average salary$41,201$38,796
Salary rangeBetween $26,000 And $62,000Between $28,000 And $53,000
Highest paying CityColumbia, MDDearborn, MI
Highest paying stateConnecticutNew Jersey
Best paying companyNTT Data International L.L.C.W. R. Berkley
Best paying industryInsuranceGovernment

Differences between claim processor and claims representative education

There are a few differences between a claim processor and a claims representative in terms of educational background:

Claim ProcessorClaims Representative
Most common degreeBachelor's Degree, 43%Bachelor's Degree, 62%
Most common majorBusinessBusiness
Most common collegeStanford UniversityStanford University

Claim processor vs claims representative demographics

Here are the differences between claim processors' and claims representatives' demographics:

Claim ProcessorClaims Representative
Average age4444
Gender ratioMale, 22.9% Female, 77.1%Male, 37.5% Female, 62.5%
Race ratioBlack or African American, 11.2% Unknown, 4.4% Hispanic or Latino, 16.7% Asian, 5.2% White, 62.0% American Indian and Alaska Native, 0.5%Black or African American, 11.0% Unknown, 4.4% Hispanic or Latino, 16.5% Asian, 5.1% White, 62.4% American Indian and Alaska Native, 0.5%
LGBT Percentage10%10%

Differences between claim processor and claims representative duties and responsibilities

Claim processor example responsibilities.

  • Experience in many facets of the managed healthcare insurance business.
  • Manage claims, route/queues, and ECHS, within specify turn- around time parameters.
  • Use ICD-9, CPT-4 and other medical manuals to adjudicate claims.
  • Analyze claims submit by providers and facilities for appropriate ICD-9, CPT and HCPCS codes against charges that are being bill.
  • Call DME and HME companies to correct invoices.
  • Coach and assist in the training of new EMR databases.
    • Show more

Claims representative example responsibilities.

  • Perform initial set-up and continuously manage claims in the Juris claims management system.
  • Investigate, evaluate, and manage call to complete coverage analysis confirming or denying coverage using Xactimate estimating software.
  • Prepare necessary state filings within statutory limits, manage litigation and vocational rehabilitation process, used appropriate cost containment techniques.
  • Assist the training department in developing CSR training in order to set expectations.
  • Create custom templates and guide sheets for new trainees in the CSR Internet division to ensure consistency and increase department efficiency.
  • Utilize proper SIU reporting procedures for extensive investigation as required.
    • Show more

Claim processor vs claims representative skills

Common claim processor skills
  • Customer Service, 20%
  • Data Entry, 8%
  • Medical Terminology, 5%
  • CPT, 5%
  • Claims Processing, 4%
  • Medical Insurance Claims, 4%
Common claims representative skills
  • Customer Service, 26%
  • Quality Standards, 6%
  • Policy Coverage, 6%
  • Reservations, 5%
  • Claims Handling, 3%
  • Insurance Coverage, 3%

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Updated January 8, 2025

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