Claim specialist vs medical claims examiner

The differences between claim specialists and medical claims examiners 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 specialist and a medical claims examiner. Additionally, a claim specialist has an average salary of $43,164, which is higher than the $42,773 average annual salary of a medical claims examiner.

The top three skills for a claim specialist include customer service, litigation and patients. The most important skills for a medical claims examiner are medical terminology, customer service, and data entry.

Claim specialist vs medical claims examiner overview

	Claim Specialist	Medical Claims Examiner
Yearly salary	$43,164	$42,773
Hourly rate	$20.75	$20.56
Growth rate	-6%	-6%
Number of jobs	29,505	57,125
Job satisfaction	-	5
Most common degree	Bachelor's Degree, 54%	Bachelor's Degree, 36%
Average age	44	44
Years of experience	6	6

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.

What does a medical claims examiner do?

A medical claims examiner determines whether an insurer will be covering losses from accidents and illness. They are responsible for evaluating insurance claims and applications, following up with insurance adjusters to protect an insurer from financial loss, ensuring information integrity, and ensuring standard guidelines are adhered to. They are also tasked with approving payment and facilitating additional investigation. Qualifications for this position include knowledge of medical terminology.

Claim specialist vs medical claims examiner salary

Claim specialists and medical claims examiners have different pay scales, as shown below.

	Claim Specialist	Medical Claims Examiner
Average salary	$43,164	$42,773
Salary range	Between $27,000 And $67,000	Between $30,000 And $59,000
Highest paying City	Newark, NJ	Los Angeles, CA
Highest paying state	New Jersey	New Jersey
Best paying company	W. R. Berkley	UST Global
Best paying industry	Insurance	Technology

Differences between claim specialist and medical claims examiner education

There are a few differences between a claim specialist and a medical claims examiner in terms of educational background:

	Claim Specialist	Medical Claims Examiner
Most common degree	Bachelor's Degree, 54%	Bachelor's Degree, 36%
Most common major	Business	Business
Most common college	Stanford University	University of Pennsylvania

Claim specialist vs medical claims examiner demographics

Here are the differences between claim specialists' and medical claims examiners' demographics:

	Claim Specialist	Medical Claims Examiner
Average age	44	44
Gender ratio	Male, 31.0% Female, 69.0%	Male, 16.6% Female, 83.4%
Race ratio	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%	Black or African American, 10.5% Unknown, 4.4% Hispanic or Latino, 17.0% Asian, 5.3% White, 62.4% American Indian and Alaska Native, 0.5%
LGBT Percentage	10%	10%

Differences between claim specialist and medical claims examiner duties and responsibilities

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.

Medical claims examiner example responsibilities.

Manage cases by aggressively directing the litigation process.
Process medical facility claims payment according to account-specific contract (HMO, PPO, EPO, etc . )
Process PPO, HMO, comprehensive plans, including medicare supplements, hospital, chiropractic and physical therapy claims.
Identify which claims are eligible for PPO reprising.
Resolve medical claims by approving and/or denying base on CMS guidelines for Medicaid/Medicare claim processing.
Verify that all ICD-9, CPT, modifiers and revenue codes are used correctly, prior to payment approval.

Claim specialist vs medical claims examiner skills

Common claim specialist skills

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

Common medical claims examiner skills

Medical Terminology, 10%
Customer Service, 9%
Data Entry, 7%
Medical Treatment, 5%
Computer System, 5%
Provider Contracts, 4%

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Claim Specialist vs Medical Claims Examiner

Updated January 8, 2025

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