Claims adjudicator vs claims representative

The differences between claims adjudicators 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 claims adjudicator and a claims representative. Additionally, a claims adjudicator has an average salary of $44,556, which is higher than the $38,796 average annual salary of a claims representative.

The top three skills for a claims adjudicator include medical terminology, CPT and disability claims. The most important skills for a claims representative are customer service, quality standards, and policy coverage.

Claims adjudicator vs claims representative overview

	Claims Adjudicator	Claims Representative
Yearly salary	$44,556	$38,796
Hourly rate	$21.42	$18.65
Growth rate	-6%	-6%
Number of jobs	12,413	18,565
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 57%	Bachelor's Degree, 62%
Average age	44	44
Years of experience	6	6

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 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.

Claims adjudicator vs claims representative salary

Claims adjudicators and claims representatives have different pay scales, as shown below.

	Claims Adjudicator	Claims Representative
Average salary	$44,556	$38,796
Salary range	Between $31,000 And $63,000	Between $28,000 And $53,000
Highest paying City	Madison, WI	Dearborn, MI
Highest paying state	New Jersey	New Jersey
Best paying company	Evolent Health	W. R. Berkley
Best paying industry	Insurance	Government

Differences between claims adjudicator and claims representative education

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

	Claims Adjudicator	Claims Representative
Most common degree	Bachelor's Degree, 57%	Bachelor's Degree, 62%
Most common major	Business	Business
Most common college	Stanford University	Stanford University

Claims adjudicator vs claims representative demographics

Here are the differences between claims adjudicators' and claims representatives' demographics:

	Claims Adjudicator	Claims Representative
Average age	44	44
Gender ratio	Male, 23.1% Female, 76.9%	Male, 37.5% Female, 62.5%
Race ratio	Black 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, 11.0% Unknown, 4.4% Hispanic or Latino, 16.5% Asian, 5.1% White, 62.4% American Indian and Alaska Native, 0.5%
LGBT Percentage	10%	10%

Differences between claims adjudicator and claims representative 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.

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.

Claims adjudicator vs claims representative skills

Common claims adjudicator skills

Medical Terminology, 9%
CPT, 8%
Disability Claims, 7%
Adjudicate Claims, 6%
Quality Standards, 6%
Medicaid, 5%

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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Claims Adjudicator
Claims Adjudicator vs Claims Representative

Updated January 8, 2025

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