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Claim processor skills for your resume and career

Updated January 8, 2025
5 min read
Claim processor example skills
Below we've compiled a list of the most critical claim processor skills. We ranked the top skills for claim processors based on the percentage of resumes they appeared on. For example, 19.5% of claim processor resumes contained customer service as a skill. Continue reading to find out what skills a claim processor needs to be successful in the workplace.

15 claim processor skills for your resume and career

1. Customer Service

Customer service is the process of offering assistance to all the current and potential customers -- answering questions, fixing problems, and providing excellent service. The main goal of customer service is to build a strong relationship with the customers so that they keep coming back for more business.

Here's how claim processors use customer service:
  • Provided customer service to claimants by greeting and interviewing individuals to determine if they met the qualifications and eligibility for funding.
  • Provided telephone customer service to participants, care management and providers regarding routine eligibility, benefits and claim status.

2. Data Entry

Data entry means entering data into a company's system with the help of a keyboard. A person responsible for entering data may also be asked to verify the authenticity of the data being entered. A person doing data entry must pay great attention to tiny details.

Here's how claim processors use data entry:
  • Conducted accurate review, processing medical claims, performing compliant data entry, adhering to established procedures and productivity requirements.
  • Provided accurate data entry of patient and provider information into claims adjudication system for timely and accurate payment of claims.

3. Medical Terminology

Here's how claim processors use medical terminology:
  • Analyzed surgery claims utilizing prior health care knowledge such as medical terminology, surgery guidelines and overall claims processing procedures.
  • Enter claims data into system while interpreting coding with comprehensive understanding of medical terminology in relation to diagnoses and procedures.

4. CPT

CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.

Here's how claim processors use cpt:
  • Maximized reimbursement by ensuring accurate CPT and Diagnosis Codes.
  • Determined eligibility and benefits for patients, interpreted provider contracts and analyzed Revenue Codes, CPT Codes, ICD-9s and HCPCS.

5. Claims Processing

Claims Processing is the entire workflow involved within the insurance company to evaluate a claim before it gets approved. It has many administrative layers such as assessing insurance eligibility, investigating the medical treatments taken, and reviewing medical codes before it settles or denies a claim with the insured healthcare provider.

Here's how claim processors use claims processing:
  • Led specialty units including high-risk management and quality assurance and drafted initial training and policy manuals for specialty claims processing units.
  • Helped train new hires in departmental procedures, also re-enforced and/or supplemented their claims processing techniques developed in corporate training.

6. Medical Insurance Claims

Here's how claim processors use medical insurance claims:
  • Maintained a high level of productivity and accuracy during acquisition of 100,000 major medical insurance claims from previous insurance carriers.
  • Processed medical insurance claims as primary, secondary and tertiary for Horizon along with various other insurances and Medicare.

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7. Provider Contracts

The definition of a provider contract is 'an agreement between a contracting entity and a provider according to which the provider agrees to deliver medical services to a claimant under this title in exchange for payment or reimbursement of an agreed-upon amount.' A provider contract relates to exactly one business partner. It consists of a contract header and contract items and details like contract start date, contract end date, authorization group, company code for authorization checks and the number of the business partner who entered the provider contract.

Here's how claim processors use provider contracts:
  • Reviewed, investigated and adjudicated claims and encounters for medical services through contractual provisions in accordance with provider contracts and authorizations.
  • Reviewed provider contracts, benefits, co-pays, deductibles, co-insurance, and authorizations to determine financial responsibility.

8. Medicaid

Here's how claim processors use medicaid:
  • Called Center for Medicaid and Medicare and patients medical insurance company to verify low income coverage.
  • Reviewed claims received from Georgia Medicaid and Medicare recipients according to State guidelines.

9. Quality Standards

Quality standards are a specific level of standards of products that are set by the companies for the customers that have to be met and maintained throughout the process until the time of delivery. Quality standards are information that includes the customer's requirements, guidelines, and characteristics for the needed final product or service.

Here's how claim processors use quality standards:
  • Processed and adjusted 70-80 claims daily, including coordination of benefits, to consistently meet established productivity and quality standards.
  • Evaluate assigned claims for validity in accordance with policy provisions, established authority limits and quality standards.

10. Excellent Negotiation

Here's how claim processors use excellent negotiation:
  • Developed excellent negotiation skills by directly engaging in negotiations and claim settlement discussions with claimants opposing counsel on a daily basis.

11. Adjudicate Claims

Here's how claim processors use adjudicate claims:
  • Reviewed claim submissions to determine medical necessity, coverage benefits and discrepancies and cost containment measures to adjudicate claims.
  • Review employment and medical records of Social Security Disability applicants and adjudicate claims according to federal guidelines.

12. ICD-9

Here's how claim processors use icd-9:
  • Investigated health insurance claims and verified accuracy, reviewed ICD-9 codes and made appropriate determination for processing of plan benefits
  • Use Medicaid processing Manuals, including: Procedure Codes, ICD-9 Diagnostic Codes, Terminology, and Medicaid guidelines and policies.

13. CMS

A Content Management System or CMS is computer software that works as a framework where content can be assembled and managed by using a database. CMS is an important asset in web development. This platform enables users to create, edit, collaborate on, publish and store digital content. It helps users to manage their content and modify it from a single system.

Here's how claim processors use cms:
  • Reviewed documents and medical information used to determine payment or denial of services based on CMS regulations and medical policy.
  • Performed quarterly inspection, quality review for verification of CMS requirements.

14. Property Damage

Property damage is the destruction or damage of tangible personal property. Property damage can be caused by negligence, irresponsible handling of the property, willful destruction, or any other destructure act of nature.

Here's how claim processors use property damage:
  • Promoted to investigate, evaluate and negotiate property damage and bodily injury settlements for commercial lines of business.
  • Investigate auto accidents resulting in property damage to ensure an equitable and accurate determination of liability is made.

15. Disability Claims

Here's how claim processors use disability claims:
  • Evaluated and adjudicated initial Social Security and Supplemental Security Income disability claims using Social Security laws, regulations, and policies.
  • Developed and applied appropriate claim and disability management techniques to ensure prompt and accurate payment decisions and management of disability claims.
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List of claim processor skills to add to your resume

The most important skills for a claim processor resume and required skills for a claim processor to have include:

  • Customer Service
  • Data Entry
  • Medical Terminology
  • CPT
  • Claims Processing
  • Medical Insurance Claims
  • Provider Contracts
  • Medicaid
  • Quality Standards
  • Excellent Negotiation
  • Adjudicate Claims
  • ICD-9
  • CMS
  • Property Damage
  • Disability Claims
  • HCPCS
  • Social Security
  • HIPAA
  • Production Standards
  • Dental Claims
  • Auto Claims
  • Claims Issues
  • Computer System
  • Claims Handling
  • COB
  • Insurance Coverage
  • Hippa
  • Insurance Policies
  • HMO
  • Policy Provisions
  • Outbound Calls
  • Compensation Claims
  • Pending Claims
  • Facets
  • Inbound Calls
  • HCFA
  • Hospital Claims
  • EOB
  • UB
  • Insurance Carriers
  • Electronic Claims
  • State Laws
  • PPO
  • Health Insurance Claims
  • Telephone Calls
  • Annuities
  • Claims Data
  • Medical Bills
  • Defense Counsel
  • Policy Holders

Updated January 8, 2025

Zippia Research Team
Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

Updated January 8, 2025

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