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Medical claims examiner vs claims adjudicator

The differences between medical claims examiners and claims adjudicators 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 examiner and a claims adjudicator. Additionally, a claims adjudicator has an average salary of $44,556, which is higher than the $42,773 average annual salary of a medical claims examiner.

The top three skills for a medical claims examiner include medical terminology, customer service and data entry. The most important skills for a claims adjudicator are medical terminology, CPT, and disability claims.

Medical claims examiner vs claims adjudicator overview

Medical Claims ExaminerClaims Adjudicator
Yearly salary$42,773$44,556
Hourly rate$20.56$21.42
Growth rate-6%-6%
Number of jobs57,12512,413
Job satisfaction5-
Most common degreeBachelor's Degree, 36%Bachelor's Degree, 57%
Average age4444
Years of experience66

What does a medical claims examiner do?

A medical claims examiner determines whether an insurer will be covering losses from accidents and illness. They are responsible for evaluating insurance claims and applications, following up with insurance adjusters to protect an insurer from financial loss, ensuring information integrity, and ensuring standard guidelines are adhered to. They are also tasked with approving payment and facilitating additional investigation. Qualifications for this position include knowledge of medical terminology.

What does a claims adjudicator do?

Claims adjudicators determine the amount of money an insurance policy owner is entitled to receive. Other names they are known for are claims adjusters and medical bill advocates. They investigate the claims filed and decide to deny, pay, or negotiate a settlement with the policyholder themselves or their representatives. The insurance companies that hire them provide insurances for property, casualty, and liability. To do their job well, they should be organized and understand how the insurance industry works.

Medical claims examiner vs claims adjudicator salary

Medical claims examiners and claims adjudicators have different pay scales, as shown below.

Medical Claims ExaminerClaims Adjudicator
Average salary$42,773$44,556
Salary rangeBetween $30,000 And $59,000Between $31,000 And $63,000
Highest paying CityLos Angeles, CAMadison, WI
Highest paying stateNew JerseyNew Jersey
Best paying companyUST GlobalEvolent Health
Best paying industryTechnologyInsurance

Differences between medical claims examiner and claims adjudicator education

There are a few differences between a medical claims examiner and a claims adjudicator in terms of educational background:

Medical Claims ExaminerClaims Adjudicator
Most common degreeBachelor's Degree, 36%Bachelor's Degree, 57%
Most common majorBusinessBusiness
Most common collegeUniversity of PennsylvaniaStanford University

Medical claims examiner vs claims adjudicator demographics

Here are the differences between medical claims examiners' and claims adjudicators' demographics:

Medical Claims ExaminerClaims Adjudicator
Average age4444
Gender ratioMale, 16.6% Female, 83.4%Male, 23.1% Female, 76.9%
Race ratioBlack or African American, 10.5% Unknown, 4.4% Hispanic or Latino, 17.0% Asian, 5.3% White, 62.4% American Indian and Alaska Native, 0.5%Black or African American, 10.5% Unknown, 4.5% Hispanic or Latino, 15.3% Asian, 6.1% White, 63.0% American Indian and Alaska Native, 0.5%
LGBT Percentage10%10%

Differences between medical claims examiner and claims adjudicator duties and responsibilities

Medical claims examiner example responsibilities.

  • Manage cases by aggressively directing the litigation process.
  • Process medical facility claims payment according to account-specific contract (HMO, PPO, EPO, etc . )
  • Process PPO, HMO, comprehensive plans, including medicare supplements, hospital, chiropractic and physical therapy claims.
  • Identify which claims are eligible for PPO reprising.
  • Resolve medical claims by approving and/or denying base on CMS guidelines for Medicaid/Medicare claim processing.
  • Verify that all ICD-9, CPT, modifiers and revenue codes are used correctly, prior to payment approval.
    • Show more

Claims adjudicator example responsibilities.

  • Manage appeals and authorizations by examining information and performing necessary adjustments.
  • Handle claims processing utilizing knowledge of medical coding standards, including HCPCS, CPT, and ICD-9.
  • Calculate refunds or credit balances involving reprocessing for partial adjustments and correct the CPT and ICD-9 codes.
  • Maintain compliance with HIPAA guidelines and regulations
  • Adjudicate claims for Medicaid, Medicare, and ambulance billing.
  • Interpret and processes routine and complex claims per Medicaid industry standards.
    • Show more

Medical claims examiner vs claims adjudicator skills

Common medical claims examiner skills
  • Medical Terminology, 10%
  • Customer Service, 9%
  • Data Entry, 7%
  • Medical Treatment, 5%
  • Computer System, 5%
  • Provider Contracts, 4%
Common claims adjudicator skills
  • Medical Terminology, 9%
  • CPT, 8%
  • Disability Claims, 7%
  • Adjudicate Claims, 6%
  • Quality Standards, 6%
  • Medicaid, 5%

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Updated January 8, 2025

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