Claims benefit specialist vs claims representative

The differences between claims benefit specialists 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 benefit specialist and a claims representative. Additionally, a claims benefit specialist has an average salary of $47,292, which is higher than the $38,796 average annual salary of a claims representative.

The top three skills for a claims benefit specialist include customer inquiries, appeals and medical terminology. The most important skills for a claims representative are customer service, quality standards, and policy coverage.

Claims benefit specialist vs claims representative overview

	Claims Benefit Specialist	Claims Representative
Yearly salary	$47,292	$38,796
Hourly rate	$22.74	$18.65
Growth rate	-6%	-6%
Number of jobs	32,208	18,565
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 40%	Bachelor's Degree, 62%
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 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 benefit specialist vs claims representative salary

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

	Claims Benefit Specialist	Claims Representative
Average salary	$47,292	$38,796
Salary range	Between $32,000 And $68,000	Between $28,000 And $53,000
Highest paying City	-	Dearborn, MI
Highest paying state	-	New Jersey
Best paying company	-	W. R. Berkley
Best paying industry	-	Government

Differences between claims benefit specialist and claims representative education

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

	Claims Benefit Specialist	Claims Representative
Most common degree	Bachelor's Degree, 40%	Bachelor's Degree, 62%
Most common major	Business	Business
Most common college	Stanford University	Stanford University

Claims benefit specialist vs claims representative demographics

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

	Claims Benefit Specialist	Claims Representative
Average age	44	44
Gender ratio	Male, 19.6% Female, 80.4%	Male, 37.5% Female, 62.5%
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, 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 benefit specialist and claims representative 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 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 benefit specialist vs claims representative skills

Common claims benefit specialist skills

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

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 Benefit Specialist
Claims Benefit Specialist vs Claims Representative

Updated January 8, 2025

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