Medical claims analyst vs claim specialist

The differences between medical claims analysts 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 medical claims analyst and a claim specialist. Additionally, a medical claims analyst has an average salary of $46,708, which is higher than the $43,164 average annual salary of a claim specialist.

The top three skills for a medical claims analyst include medical terminology, medicaid and medical insurance claims. The most important skills for a claim specialist are customer service, litigation, and patients.

Medical claims analyst vs claim specialist overview

	Medical Claims Analyst	Claim Specialist
Yearly salary	$46,708	$43,164
Hourly rate	$22.46	$20.75
Growth rate	-6%	-6%
Number of jobs	65,897	29,505
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 54%
Average age	44	44
Years of experience	6	6

What does a medical claims analyst do?

A medical claims analyst audits or verifies medical claims in insurance companies. Medical claims analysts make sure that corporate reimbursement payments are accurate. Usually, they work at an office on a computer workstation. They receive Medicaid claims from specialty and medical providers for reimbursement. Their job includes the development of an enhanced procedure in handling difficult Medicare/Medicaid letters while complying with the set policies.

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.

Medical claims analyst vs claim specialist salary

Medical claims analysts and claim specialists have different pay scales, as shown below.

	Medical Claims Analyst	Claim Specialist
Average salary	$46,708	$43,164
Salary range	Between $32,000 And $68,000	Between $27,000 And $67,000
Highest paying City	Bridgewater, NJ	Newark, NJ
Highest paying state	New Jersey	New Jersey
Best paying company	Montefiore Mount Vernon Hospital	W. R. Berkley
Best paying industry	Insurance	Insurance

Differences between medical claims analyst and claim specialist education

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

	Medical Claims Analyst	Claim Specialist
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 54%
Most common major	Business	Business
Most common college	University of Pennsylvania	Stanford University

Medical claims analyst vs claim specialist demographics

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

	Medical Claims Analyst	Claim Specialist
Average age	44	44
Gender ratio	Male, 14.2% Female, 85.8%	Male, 31.0% Female, 69.0%
Race ratio	Black or African American, 11.2% Unknown, 4.4% Hispanic or Latino, 16.4% 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 medical claims analyst and claim specialist duties and responsibilities

Medical claims analyst example responsibilities.

Manage cases by aggressively directing the litigation process.
Analyze incoming medical claims using ICD-9, CPT, HCPCS coding, and Medicare fee schedules.
Determine if claims are in compliance under patient benefit plans for payments using DRG regulations :
Review medical records to determine if the ICD-9, CPT codes and modifiers are processed correctly.
Adhere to the HIPAA privacy, security regulations, and maintain confidentiality of patient a business records.
Research medical claims issues in response to informational inquiries by accessing and interpreting EOB's and claims history.

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.

Medical claims analyst vs claim specialist skills

Common medical claims analyst skills

Medical Terminology, 9%
Medicaid, 6%
Medical Insurance Claims, 6%
Customer Service, 6%
Data Entry, 6%
Patients, 5%

Common claim specialist skills

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

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Medical Claims Analyst
Medical Claims Analyst vs Claim Specialist

Updated January 8, 2025

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