Claims representative vs claim specialist

The differences between claims representatives 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 representative and a claim specialist. Additionally, a claim specialist has an average salary of $43,164, which is higher than the $38,796 average annual salary of a claims representative.

The top three skills for a claims representative include customer service, quality standards and policy coverage. The most important skills for a claim specialist are customer service, litigation, and patients.

Claims representative vs claim specialist overview

	Claims Representative	Claim Specialist
Yearly salary	$38,796	$43,164
Hourly rate	$18.65	$20.75
Growth rate	-6%	-6%
Number of jobs	18,565	29,505
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 62%	Bachelor's Degree, 54%
Average age	44	44
Years of experience	6	6

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.

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 representative vs claim specialist salary

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

	Claims Representative	Claim Specialist
Average salary	$38,796	$43,164
Salary range	Between $28,000 And $53,000	Between $27,000 And $67,000
Highest paying City	Dearborn, MI	Newark, NJ
Highest paying state	New Jersey	New Jersey
Best paying company	W. R. Berkley	W. R. Berkley
Best paying industry	Government	Insurance

Differences between claims representative and claim specialist education

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

	Claims Representative	Claim Specialist
Most common degree	Bachelor's Degree, 62%	Bachelor's Degree, 54%
Most common major	Business	Business
Most common college	Stanford University	Stanford University

Claims representative vs claim specialist demographics

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

	Claims Representative	Claim Specialist
Average age	44	44
Gender ratio	Male, 37.5% Female, 62.5%	Male, 31.0% Female, 69.0%
Race ratio	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%	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 Percentage	10%	10%

Differences between claims representative and claim specialist duties and responsibilities

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.

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.

Claims representative vs claim specialist skills

Common claims representative skills

Customer Service, 26%
Quality Standards, 6%
Policy Coverage, 6%
Reservations, 5%
Claims Handling, 3%
Insurance Coverage, 3%

Common claim specialist skills

Customer Service, 19%
Litigation, 7%
Patients, 5%
Claims Handling, 4%
Quality Standards, 4%
Excellent Organizational, 4%

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Claims Representative vs Claim Specialist

Updated January 8, 2025

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