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Claims adjudicator vs claim specialist

The differences between claims adjudicators and claim specialists 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 specialist. Additionally, a claims adjudicator has an average salary of $44,556, which is higher than the $43,164 average annual salary of a claim specialist.

The top three skills for a claims adjudicator include medical terminology, CPT and disability claims. The most important skills for a claim specialist are customer service, litigation, and patients.

Claims adjudicator vs claim specialist overview

Claims AdjudicatorClaim Specialist
Yearly salary$44,556$43,164
Hourly rate$21.42$20.75
Growth rate-6%-6%
Number of jobs12,41329,505
Job satisfaction--
Most common degreeBachelor's Degree, 57%Bachelor's Degree, 54%
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 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.

Claims adjudicator vs claim specialist salary

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

Claims AdjudicatorClaim Specialist
Average salary$44,556$43,164
Salary rangeBetween $31,000 And $63,000Between $27,000 And $67,000
Highest paying CityMadison, WINewark, NJ
Highest paying stateNew JerseyNew Jersey
Best paying companyEvolent HealthW. R. Berkley
Best paying industryInsuranceInsurance

Differences between claims adjudicator and claim specialist education

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

Claims AdjudicatorClaim Specialist
Most common degreeBachelor's Degree, 57%Bachelor's Degree, 54%
Most common majorBusinessBusiness
Most common collegeStanford UniversityStanford University

Claims adjudicator vs claim specialist demographics

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

Claims AdjudicatorClaim Specialist
Average age4444
Gender ratioMale, 23.1% Female, 76.9%Male, 31.0% Female, 69.0%
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, 11.4% Unknown, 4.4% Hispanic or Latino, 16.5% Asian, 5.1% White, 62.1% American Indian and Alaska Native, 0.5%
LGBT Percentage10%10%

Differences between claims adjudicator and claim specialist 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 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.
    • Show more

Claims adjudicator vs claim specialist skills

Common claims adjudicator skills
  • Medical Terminology, 9%
  • CPT, 8%
  • Disability Claims, 7%
  • Adjudicate Claims, 6%
  • Quality Standards, 6%
  • Medicaid, 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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