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.
Medical claims analyst responsibilities
Here are examples of responsibilities from real medical claims analyst resumes:
- 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.
- Follow all applicable Medi-Cal and Medicare government regulations including HIPPA.
- Receive Medicaid claims from medical and specialty providers to determine reimbursement.
- Bill insurance companies electronically and resolve EOB issues regarding insurance payment.
- Audit data handling during transitional process, report issues legal department and HIPPA compliance officer to ensure confidentiality and regulatory compliance.
- Develop an enhance procedure to handle difficult Medicaid/Medicare letters while staying in compliance.
- Work closely with attorneys on litigate claims to help facilitate settlements and resolution, to include mediation and arbitration.
- Enter and perform adjudication process for HSA and FSA claims for various company's employees to receive payment's.
- Adjudicate incoming claims in accordance with policy, procedures guide lines as outlined by Cigna.
- Assist in the processing of medical, dental and vision claims from multiple lines of business within Cigna.
Medical claims analyst skills and personality traits
We calculated that 9% of Medical Claims Analysts are proficient in Medical Terminology, Medicaid, and Medical Insurance Claims. They’re also known for soft skills such as Interpersonal skills, Analytical skills, and Detail oriented.
We break down the percentage of Medical Claims Analysts that have these skills listed on their resume here:
- Medical Terminology, 9%
Evaluated medical claims utilizing medical terminology.
- Medicaid, 6%
Interpret Manage Care contracts and/or Medicare and Medicaid rules and regulations to ensure proper reimbursement/collections.
- Medical Insurance Claims, 6%
Processed medical insurance claims as a third party administrator.
- Customer Service, 6%
Provided customer service for claims and maintained very high quality and productivity goals
- Data Entry, 6%
Performed data entry of medical claims according to state regulations or usual and customary guide lines
- Patients, 5%
Reviewed primary care physician referrals to direct patients to their approved specialists.
Most medical claims analysts use their skills in "medical terminology," "medicaid," and "medical insurance claims" to do their jobs. You can find more detail on essential medical claims analyst responsibilities here:
Interpersonal skills. The most essential soft skill for a medical claims analyst to carry out their responsibilities is interpersonal skills. This skill is important for the role because "adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering." Additionally, a medical claims analyst resume shows how their duties depend on interpersonal skills: "position required excellent interpersonal skills, and ability to understand and interpret policy provisions utilizing insurance codes. "
Analytical skills. Another essential skill to perform medical claims analyst duties is analytical skills. Medical claims analysts responsibilities require that "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay." Medical claims analysts also use analytical skills in their role according to a real resume snippet: "research ub and hcfa medical claims * create spreadsheets to reflect research and data. "
Detail oriented. This is an important skill for medical claims analysts to perform their duties. For an example of how medical claims analyst responsibilities depend on this skill, consider that "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." This excerpt from a resume also shows how vital it is to everyday roles and responsibilities of a medical claims analyst: "team orientated individual who enjoys providing excellent customer service and enjoys paying attention to details. ".
Communication skills. Lastly, "communication skills" is an important element of what a medical claims analyst does. Medical claims analyst responsibilities require this skill because "claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts." This resume example highlights how medical claims analyst duties rely on this skill: "communicated orally and by written communication with all payors, offices, and patients. "
The three companies that hire the most medical claims analysts are:
- Change Healthcare14 medical claims analysts jobs
- Montefiore Mount Vernon Hospital2 medical claims analysts jobs
- Alaffia2 medical claims analysts jobs
Choose from 10+ customizable medical claims analyst resume templates
Build a professional medical claims analyst resume in minutes. Our AI resume writing assistant will guide you through every step of the process, and you can choose from 10+ resume templates to create your medical claims analyst resume.
Compare different medical claims analysts
Medical claims analyst vs. Adjuster
An adjuster is responsible for evaluating the extent of loss in the company by calculating the damage costs, determining the settlement payment to the client, and managing the reputation of the company for claims accountability. Adjusters must have extensive knowledge of the insurance principles and processes, following the state and federal regulations to protect clients and the business from insurance fraud. They collect documents from different organizations, perform field research, and interview witnesses to verify the accuracy of claims statement.
These skill sets are where the common ground ends though. The responsibilities of a medical claims analyst are more likely to require skills like "medical terminology," "medicaid," "medical insurance claims," and "data entry." On the other hand, a job as an adjuster requires skills like "strong customer service," "litigation," "liability claims," and "policy coverage." As you can see, what employees do in each career varies considerably.
Adjusters really shine in the insurance industry with an average salary of $50,894. Comparatively, medical claims analysts tend to make the most money in the insurance industry with an average salary of $49,384.On average, adjusters reach similar levels of education than medical claims analysts. Adjusters are 1.1% less likely to earn a Master's Degree and 0.8% more likely to graduate with a Doctoral Degree.Medical claims analyst vs. Insurance adjuster
Worker's Compensation Claims Examiners are responsible for managing the overall process of compensation claims for workers. They review accurate submission of claim documents, determine the appropriateness of compensation, and finalize the amount before authorizing payment to the respective worker. Other duties include ensuring claims adhere to workers' compensation law and follow proper guidelines. A Worker Compensation Claims Examiner normally work for life insurance or health companies.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that medical claims analyst responsibilities requires skills like "medical terminology," "medicaid," "medical insurance claims," and "data entry." But an insurance adjuster might use other skills in their typical duties, such as, "insurance policies," "liability claims," "auto claims," and "catastrophe claims."
On average, insurance adjusters earn a higher salary than medical claims analysts. Some industries support higher salaries in each profession. Interestingly enough, insurance adjusters earn the most pay in the insurance industry with an average salary of $60,583. Whereas medical claims analysts have higher pay in the insurance industry, with an average salary of $49,384.insurance adjusters earn similar levels of education than medical claims analysts in general. They're 0.6% less likely to graduate with a Master's Degree and 0.8% more likely to earn a Doctoral Degree.Medical claims analyst vs. Worker's compensation claims examiner
A Claims Processor is responsible for processing and verifying insurance claims, in adherence to the policies, laws, and regulations of the company involved. Aside from examining its authenticity, they must also oversee new policies and recommend modifications should it be needed. Moreover, it is also the task of the Claims Processor to prepare the necessary documents and guidelines for the policyholder, process reimbursements upon approval, provide answers to inquiries, and report issues and updates to the management.
Some important key differences between the two careers include a few of the skills necessary to fulfill the responsibilities of each. Some examples from medical claims analyst resumes include skills like "medical terminology," "medicaid," "medical insurance claims," and "customer service," whereas a worker's compensation claims examiner is more likely to list skills in "rehabilitation," "calculates," "social security," and "litigation. "
Workers's compensation claims examiner earn the best pay in the finance industry, where they command an average salary of $87,601. Medical claims analysts earn the highest pay from the insurance industry, with an average salary of $49,384.Most workers's compensation claims examiner achieve a similar degree level compared to medical claims analysts. For example, they're 0.4% more likely to graduate with a Master's Degree, and 0.6% more likely to earn a Doctoral Degree.Medical claims analyst vs. Claim processor
Types of medical claims analyst
Updated January 8, 2025
