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Claims adjudicator skills for your resume and career

Updated January 8, 2025
3 min read
Below we've compiled a list of the most critical claims adjudicator skills. We ranked the top skills for claims adjudicators based on the percentage of resumes they appeared on. For example, 8.8% of claims adjudicator resumes contained medical terminology as a skill. Continue reading to find out what skills a claims adjudicator needs to be successful in the workplace.

15 claims adjudicator skills for your resume and career

1. Medical Terminology

Here's how claims adjudicators use medical terminology:
  • Required knowledge of medical terminology and appropriateness of treatment.
  • Processed medical claims through payment, including knowledge of ICD-9, CPT-4 coding and medical terminology.

2. 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 claims adjudicators use cpt:
  • Handled claims processing utilizing knowledge of medical coding standards, including HCPCS, CPT, and ICD-9.
  • Apply procedure and diagnostic (ICD-9), CPT codes to medical services.

3. Disability Claims

Here's how claims adjudicators use disability claims:
  • Process disability claims for benefits under the Social Security Disability Insurance and Supplemental Security Income Disability Programs.
  • Ensured compliance with disability policy provisions-Analyzed medical information and adjudicated short term disability claims-Trained new claims adjudicators

4. Adjudicate Claims

Here's how claims adjudicators use adjudicate claims:
  • Maintain and update required reference materials to adjudicate claims.
  • Coordinate and enforces Social Security and HIPAA policies, procedures, rules and regulations in order to efficiently adjudicate claims.

5. 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 claims adjudicators use quality standards:
  • Maintained quality standards and exceeded production goals of case development and completion.
  • Maintain all productivity goals, quality standards, and aging timeframes.

6. Medicaid

Here's how claims adjudicators use medicaid:
  • Implemented Health Plan benefit payments to Providers based on the contract rates of Provider, Medicare and/or Medicaid (CMS).
  • Review and adjudicate fee for service claims for CMS (Centers for Medicare and Medicaid Services).

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7. Home Health

Here's how claims adjudicators use home health:
  • Reviewed, determined and processed home health claims payments and denials based on carrier health plans.
  • Provide review and pre-certification of ancillary services, durable medical equipment and home health services.

8. Social Security Administration

Here's how claims adjudicators use social security administration:
  • Conduct phone interviews with claimants and compare their allegations and gathered information with the disability guidelines of the Social Security Administration.
  • Analyze relevant data to draft decisions as to claimants' eligibility in accordance with Social Security Administration program regulations and guidelines.

9. 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 claims adjudicators use cms:
  • Ensured quality administration of CMS regulations.
  • Interpret and process routine and less complex claims including CMS 1500 and UB04.

10. HCPCS

Here's how claims adjudicators use hcpcs:
  • Review documentation, analyze rejected claim data, justify CPT & HCPCS codes and pay HCFA-1500 and UB92 claims.
  • Detailed knowledge of medical coding; ICD-9, CPT and HCPCS codes.

11. Medical Claims

Here's how claims adjudicators use medical claims:
  • Coached Claims Processing Clerks and Medical Claims Adjudicators, along with lower level eligibility department on specific processes.
  • Review medical claims to verify information and process physician payments and member reimbursements.

12. Appeals

Here's how claims adjudicators use appeals:
  • Assisted individuals and provide guidance in the appeals process.
  • Assessed the appeals of processed to determine appropriate payment.

13. HMO

Here's how claims adjudicators use hmo:
  • Handled assigned HMO group claims, utilizing my medical knowledge for payment .
  • Review and process claims/encounters based upon eligibility, benefits, authorizations and contractual agreements between the HMO and providers.

14. Process Claims

Process claims refers to the procedure an insurance agent follows once receiving a claim from an insured individual. This often includes reviewing, investigating, and deciding on whether the claim will be accepted or denied depending on the results of the insurer's investigation. This is a common procedure for all kinds of insurance including medical, auto, and liability insurance.

Here's how claims adjudicators use process claims:
  • Reviewed and analyzed data from system generated reports for in-process claims and resolve errors prior to final adjudication.
  • Process claims for payment, verified insurance coverage, requested information from both provider and patient, generated EOB's

15. HIPAA

Here's how claims adjudicators use hipaa:
  • Adhered to and participating in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
  • Worked on HIPAA EDI X12N - 837 record edits to facilitate Auto Adjudication.
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List of claims adjudicator skills to add to your resume

The most important skills for a claims adjudicator resume and required skills for a claims adjudicator to have include:

  • Medical Terminology
  • CPT
  • Disability Claims
  • Adjudicate Claims
  • Quality Standards
  • Medicaid
  • Home Health
  • Social Security Administration
  • CMS
  • HCPCS
  • Medical Claims
  • Appeals
  • HMO
  • Process Claims
  • HIPAA
  • Health Insurance Claims
  • Pending Claims
  • Dental Claims
  • Medical Evidence
  • Computer System
  • Disability Benefits
  • Medi-Cal
  • Social Security ACT
  • ICD-9
  • Physician Contracts
  • Plan Benefits
  • COB
  • Claims System
  • Health Plan
  • TPA
  • Hippa
  • UB
  • Questionable Claims
  • HCFA
  • Title II
  • Unemployment Claims
  • Medical Facilities
  • Hospital Claims
  • Production Standards
  • Ub04
  • Program Eligibility
  • Electronic Claims
  • Past Work
  • EOB
  • Questionable Data
  • FSA

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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