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Claims adjudicator vs claim processor

The differences between claims adjudicators and claim processors can be seen in a few details. Each job has different responsibilities and duties. It typically takes 4-6 years to become both a claims adjudicator and a claim processor. Additionally, a claims adjudicator has an average salary of $44,556, which is higher than the $41,201 average annual salary of a claim processor.

The top three skills for a claims adjudicator include medical terminology, CPT and disability claims. The most important skills for a claim processor are customer service, data entry, and medical terminology.

Claims adjudicator vs claim processor overview

Claims AdjudicatorClaim Processor
Yearly salary$44,556$41,201
Hourly rate$21.42$19.81
Growth rate-6%-6%
Number of jobs12,41311,542
Job satisfaction--
Most common degreeBachelor's Degree, 57%Bachelor's Degree, 43%
Average age4444
Years of experience66

What does a claims adjudicator do?

Claims adjudicators determine the amount of money an insurance policy owner is entitled to receive. Other names they are known for are claims adjusters and medical bill advocates. They investigate the claims filed and decide to deny, pay, or negotiate a settlement with the policyholder themselves or their representatives. The insurance companies that hire them provide insurances for property, casualty, and liability. To do their job well, they should be organized and understand how the insurance industry works.

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.

Claims adjudicator vs claim processor salary

Claims adjudicators and claim processors have different pay scales, as shown below.

Claims AdjudicatorClaim Processor
Average salary$44,556$41,201
Salary rangeBetween $31,000 And $63,000Between $26,000 And $62,000
Highest paying CityMadison, WIColumbia, MD
Highest paying stateNew JerseyConnecticut
Best paying companyEvolent HealthNTT Data International L.L.C.
Best paying industryInsuranceInsurance

Differences between claims adjudicator and claim processor education

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

Claims AdjudicatorClaim Processor
Most common degreeBachelor's Degree, 57%Bachelor's Degree, 43%
Most common majorBusinessBusiness
Most common collegeStanford UniversityStanford University

Claims adjudicator vs claim processor demographics

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

Claims AdjudicatorClaim Processor
Average age4444
Gender ratioMale, 23.1% Female, 76.9%Male, 22.9% Female, 77.1%
Race ratioBlack or African American, 10.5% Unknown, 4.5% Hispanic or Latino, 15.3% Asian, 6.1% White, 63.0% American Indian and Alaska Native, 0.5%Black 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%
LGBT Percentage10%10%

Differences between claims adjudicator and claim processor duties and responsibilities

Claims adjudicator example responsibilities.

  • Manage appeals and authorizations by examining information and performing necessary adjustments.
  • Handle claims processing utilizing knowledge of medical coding standards, including HCPCS, CPT, and ICD-9.
  • Calculate refunds or credit balances involving reprocessing for partial adjustments and correct the CPT and ICD-9 codes.
  • Maintain compliance with HIPAA guidelines and regulations
  • Adjudicate claims for Medicaid, Medicare, and ambulance billing.
  • Interpret and processes routine and complex claims per Medicaid industry standards.
    • Show more

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 adjudicator vs claim processor skills

Common claims adjudicator skills
  • Medical Terminology, 9%
  • CPT, 8%
  • Disability Claims, 7%
  • Adjudicate Claims, 6%
  • Quality Standards, 6%
  • Medicaid, 5%
Common claim processor skills
  • Customer Service, 20%
  • Data Entry, 8%
  • Medical Terminology, 5%
  • CPT, 5%
  • Claims Processing, 4%
  • Medical Insurance Claims, 4%

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Updated January 8, 2025

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