Claims benefit specialist vs claims adjudicator

The differences between claims benefit specialists and claims adjudicators 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 benefit specialist and a claims adjudicator. Additionally, a claims benefit specialist has an average salary of $47,292, which is higher than the $44,556 average annual salary of a claims adjudicator.

The top three skills for a claims benefit specialist include customer inquiries, appeals and medical terminology. The most important skills for a claims adjudicator are medical terminology, CPT, and disability claims.

Claims benefit specialist vs claims adjudicator overview

	Claims Benefit Specialist	Claims Adjudicator
Yearly salary	$47,292	$44,556
Hourly rate	$22.74	$21.42
Growth rate	-6%	-6%
Number of jobs	32,208	12,413
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 40%	Bachelor's Degree, 57%
Average age	44	44
Years of experience	6	6

What does a claims benefit specialist do?

Claims and benefits specialists ensure their company's compliance with the internal and external health plan partner processes. The job requires them to be sharp, organized, and able to multitask. They recommend strategies that will improve the processes present in the current trends that they constantly evaluate. These specialists manage portfolios of claims and benefits issues and ensure that they provide the best resolutions that follow the health plan processing guidelines to impress their clients.

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.

Claims benefit specialist vs claims adjudicator salary

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

	Claims Benefit Specialist	Claims Adjudicator
Average salary	$47,292	$44,556
Salary range	Between $32,000 And $68,000	Between $31,000 And $63,000
Highest paying City	-	Madison, WI
Highest paying state	-	New Jersey
Best paying company	-	Evolent Health
Best paying industry	-	Insurance

Differences between claims benefit specialist and claims adjudicator education

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

	Claims Benefit Specialist	Claims Adjudicator
Most common degree	Bachelor's Degree, 40%	Bachelor's Degree, 57%
Most common major	Business	Business
Most common college	Stanford University	Stanford University

Claims benefit specialist vs claims adjudicator demographics

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

	Claims Benefit Specialist	Claims Adjudicator
Average age	44	44
Gender ratio	Male, 19.6% Female, 80.4%	Male, 23.1% Female, 76.9%
Race ratio	Black or African American, 11.4% Unknown, 4.4% Hispanic or Latino, 16.9% Asian, 5.2% White, 61.6% American Indian and Alaska Native, 0.5%	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%
LGBT Percentage	10%	10%

Differences between claims benefit specialist and claims adjudicator duties and responsibilities

Claims benefit specialist example responsibilities.

Analyze, process and manage FMLA claims to determine eligibility and certification in compliance with state and federal regulations.
Establish a working knowledge of CPT, ICD-9, HCPCS codes, terminology, member benefits and claim flow.
Process claims utilizing appropriate ICD-9, DSM-IV and HCPCS codes.
Analyze each claim and calculate percentages for both PPO and NON-PPO providers.
Understand CPT, HCPCS, ICD-9-CM and ICD-10-CM medical claims coding regulations and guidelines
Process Non-HMO and PPO paper and electronic claims in an accurate and time manner.

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 benefit specialist vs claims adjudicator skills

Common claims benefit specialist skills

Customer Inquiries, 11%
Appeals, 7%
Medical Terminology, 6%
Routine Claims, 5%
CPT, 4%
Processing Issues, 4%

Common claims adjudicator skills

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

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Claims Benefit Specialist
Claims Benefit Specialist vs Claims Adjudicator

Updated January 8, 2025

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