What does an insurance claims processor do?
A claims processor usually works in health or property insurance claims. They are responsible for processing and evaluating the claim forms, monitoring and verifying information, and closely communicating with the company's clients, beneficiaries, and agents. Also, they handle queries and comments, calculate possible claims, and process of various payments. They also need to ensure all insurance company guidelines and policies are adhered to in order to avoid discrepancies, issues, and other problems regarding a client's claims.
Insurance claims processor responsibilities
Here are examples of responsibilities from real insurance claims processor resumes:
- Manage cases by aggressively directing the litigation process.
- Maintain confidentiality in accordance with HIPAA laws.
- Process ICD-9 codes, diagnostic and procedure codes.
- Handle confidential information according to HIPPA and JAACHO standards.
- Follow and comply with HIPPA rules and regulations to ensure patient privacy.
- Process medical and dental claims using appropriate CPT, ICD-9, and ADA coding.
- Pull medical explanation of benefit (EOB) forms for several categories of insurance.
- Generate communication between Medicaid and customers.
- Process a number of different Medicaid insurance claims
- Prepare and submit insurance claims to third-party payers via electronic transmission following HIPAA regulations.
- Prepare deposition and medical records summaries along with exhibits and other case-relate materials for medical malpractice litigation.
- Work with FHA and VA loans to ensure accuracy in mortgage files.
- Obtain necessary documents when missing from file to post close and insure FHA government loans.
- Hire to reduce A/R by consistently and persistently working deny claims, while also posting all patient and insurance payments.
- Schedule appropriate resources to investigate claims for subrogation, arbitration, risk management, and fraudulent activity.
Insurance claims processor skills and personality traits
We calculated that 18% of Insurance Claims Processors are proficient in Data Entry, Customer Service, and Medicaid. They’re also known for soft skills such as Communication skills, Math skills, and Organizational skills.
We break down the percentage of Insurance Claims Processors that have these skills listed on their resume here:
- Data Entry, 18%
Filled out any necessary patient information for data entry.
- Customer Service, 11%
Provided general information for complaint calls Completed detailed reports on all complaint calls Provided General Customer Service
- Medicaid, 8%
Processed a number of different Medicaid insurance claims
- Medical Terminology, 6%
Required knowledge of ICD 9 codes, CPT codes, Procedure codes and Medical Terminology.
- Insurance Coverage, 5%
Ensured homeowners maintained proper insurance coverage and monitored accounts.
- ICD-9, 4%
Processed health insurance claims based on ICD-9 indentified procedures.
Common skills that an insurance claims processor uses to do their job include "data entry," "customer service," and "medicaid." You can find details on the most important insurance claims processor responsibilities below.
Communication skills. To carry out their duties, the most important skill for an insurance claims processor to have is communication skills. Their role and responsibilities require that "financial clerks should be able to explain policies and procedures to colleagues and customers." Insurance claims processors often use communication skills in their day-to-day job, as shown by this real resume: "generated communication between medicaid and customers. "
Math skills. Another soft skill that's essential for fulfilling insurance claims processor duties is math skills. The role rewards competence in this skill because "the job duties of financial clerks includes calculating charges and updating financial records." According to an insurance claims processor resume, here's how insurance claims processors can utilize math skills in their job responsibilities: "tracked insurance payment statistics for 2 chiropractors and 1 massage therapist. "
Organizational skills. Another skill that relates to the job responsibilities of insurance claims processors is organizational skills. This skill is critical to many everyday insurance claims processor duties, as "financial clerks must be able to arrange files so they can find them quickly and efficiently." This example from a resume shows how this skill is used: "maintain quality financial claims service by following corporate customer service practices and organizational standards. "
The three companies that hire the most insurance claims processors are:
- The Reserves Network2 insurance claims processors jobs
- Insurance Administrative Solutions2 insurance claims processors jobs
- Kelly Services1 insurance claims processors jobs
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Compare different insurance claims processors
Insurance claims processor vs. Medical billing clerk
A medical billing clerk is primarily in charge of processing payments and creating billing arrangements in clinics and hospitals. Among their responsibilities include gathering and verifying patient identification, handling insurance information, coding, updating databases, and maintaining records. It is also their responsibility to assist patients by filling out forms, answering their inquiries, and referring them to other services. Moreover, a medical billing clerk must monitor patient accounts and follow-up on delinquent patient accounts, coordinating with collection agencies as needed.
There are some key differences in the responsibilities of each position. For example, insurance claims processor responsibilities require skills like "inbound calls," "insurance policies," "policy holders," and "health insurance claims." Meanwhile a typical medical billing clerk has skills in areas such as "patients," "medical billing," "healthcare," and "medical claims." This difference in skills reveals the differences in what each career does.
Medical billing clerks really shine in the health care industry with an average salary of $34,137. Comparatively, insurance claims processors tend to make the most money in the insurance industry with an average salary of $38,285.The education levels that medical billing clerks earn slightly differ from insurance claims processors. In particular, medical billing clerks are 1.9% less likely to graduate with a Master's Degree than an insurance claims processor. Additionally, they're 0.2% less likely to earn a Doctoral Degree.Insurance claims processor vs. Process associate
Process Associates are responsible for maintaining, monitoring, and improving the production processes for manufacturing organizations. They are responsible for inspecting existing processes to guide system upgrades, servicing production equipment, maintaining supplies and inventory, and adhering to safety and quality regulations for production processes. Process associates also write production process reports and help to troubleshoot issues pertinent to processes. They must be detailed oriented and possess technical knowledge of mechanical processes. A goof process associate will maintain the smooth running to achieve cost reduction and production rate improvement.
In addition to the difference in salary, there are some other key differences worth noting. For example, insurance claims processor responsibilities are more likely to require skills like "medical terminology," "insurance coverage," "icd-9," and "inbound calls." Meanwhile, a process associate has duties that require skills in areas such as "patients," "extraction," "business process," and "hr." These differences highlight just how different the day-to-day in each role looks.
Process associates earn similar levels of education than insurance claims processors in general. They're 4.8% more likely to graduate with a Master's Degree and 0.2% less likely to earn a Doctoral Degree.Insurance claims processor vs. Claims manager
A claims manager is an individual who works in an insurance-based firm and is responsible for managing the insurance claims department that is composed of examiners and adjusters. Claims managers are required to maintain claim files and reviewing these files as well as communicate with customers to follow up regarding issues they face with insurance claims. They must determine who is liable for the damage if there were other parties involved. Claims managers must also include an expert to assess the amount of damage and avoid insurance fraud.
The required skills of the two careers differ considerably. For example, insurance claims processors are more likely to have skills like "data entry," "medical terminology," "insurance coverage," and "inbound calls." But a claims manager is more likely to have skills like "oversight," "litigation," "direct reports," and "claims handling."
Claims managers make a very good living in the insurance industry with an average annual salary of $81,729. On the other hand, insurance claims processors are paid the highest salary in the insurance industry, with average annual pay of $38,285.Most claims managers achieve a similar degree level compared to insurance claims processors. For example, they're 3.6% more likely to graduate with a Master's Degree, and 2.5% more likely to earn a Doctoral Degree.Insurance claims processor vs. Claims service representative
Claims service representatives evaluate customer insurance claims. Their tasks in this career include interviewing witnesses or customers and visiting accident sites to assess the scope of the claim. Also, they determine whether it is worth arranging a settlement and make sure all settlement claims are managed quickly. In addition to evaluating accidents and claims, they renew customer policies based on their history. Qualifications for the job include a firm knowledge of overall company policy, computer literacy, and excellent customer service.
Even though a few skill sets overlap between insurance claims processors and claims service representatives, there are some differences that are important to note. For one, an insurance claims processor might have more use for skills like "data entry," "medical terminology," "cpt-4," and "insurance verification." Meanwhile, some responsibilities of claims service representatives require skills like "insurance claims," "policy coverage," "phone calls," and "claims process. "
The government industry tends to pay the highest salaries for claims service representatives, with average annual pay of $38,986. Comparatively, the highest insurance claims processor annual salary comes from the insurance industry.The average resume of claims service representatives showed that they earn similar levels of education compared to insurance claims processors. So much so that theyacirc;euro;trade;re 0.4% more likely to earn a Master's Degree and less likely to earn a Doctoral Degree by 0.1%.Types of insurance claims processor
Updated January 8, 2025
