Medical claims analyst vs claims representative

The differences between medical claims analysts 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 medical claims analyst and a claims representative. Additionally, a medical claims analyst has an average salary of $46,708, which is higher than the $38,796 average annual salary of a claims representative.

The top three skills for a medical claims analyst include medical terminology, medicaid and medical insurance claims. The most important skills for a claims representative are customer service, quality standards, and policy coverage.

Medical claims analyst vs claims representative overview

	Medical Claims Analyst	Claims Representative
Yearly salary	$46,708	$38,796
Hourly rate	$22.46	$18.65
Growth rate	-6%	-6%
Number of jobs	65,897	18,565
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 62%
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 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.

Medical claims analyst vs claims representative salary

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

	Medical Claims Analyst	Claims Representative
Average salary	$46,708	$38,796
Salary range	Between $32,000 And $68,000	Between $28,000 And $53,000
Highest paying City	Bridgewater, NJ	Dearborn, MI
Highest paying state	New Jersey	New Jersey
Best paying company	Montefiore Mount Vernon Hospital	W. R. Berkley
Best paying industry	Insurance	Government

Differences between medical claims analyst and claims representative education

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

	Medical Claims Analyst	Claims Representative
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 62%
Most common major	Business	Business
Most common college	University of Pennsylvania	Stanford University

Medical claims analyst vs claims representative demographics

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

	Medical Claims Analyst	Claims Representative
Average age	44	44
Gender ratio	Male, 14.2% Female, 85.8%	Male, 37.5% Female, 62.5%
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, 11.0% 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 medical claims analyst and claims representative 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.

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.

Medical claims analyst vs claims representative skills

Common medical claims analyst skills

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

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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Medical Claims Analyst vs Claims Representative

Updated January 8, 2025

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