Medical claims examiner vs claims benefit specialist

The differences between medical claims examiners and claims benefit 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 examiner and a claims benefit specialist. Additionally, a claims benefit specialist has an average salary of $47,292, 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 benefit specialist are customer inquiries, appeals, and medical terminology.

Medical claims examiner vs claims benefit specialist overview

	Medical Claims Examiner	Claims Benefit Specialist
Yearly salary	$42,773	$47,292
Hourly rate	$20.56	$22.74
Growth rate	-6%	-6%
Number of jobs	57,125	32,208
Job satisfaction	5	-
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 40%
Average age	44	44
Years of experience	6	6

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 benefit specialist do?

Claims and benefits specialists ensure their company's compliance with the internal and external health plan partner processes. The job requires them to be sharp, organized, and able to multitask. They recommend strategies that will improve the processes present in the current trends that they constantly evaluate. These specialists manage portfolios of claims and benefits issues and ensure that they provide the best resolutions that follow the health plan processing guidelines to impress their clients.

Medical claims examiner vs claims benefit specialist salary

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

	Medical Claims Examiner	Claims Benefit Specialist
Average salary	$42,773	$47,292
Salary range	Between $30,000 And $59,000	Between $32,000 And $68,000
Highest paying City	Los Angeles, CA	-
Highest paying state	New Jersey	-
Best paying company	UST Global	-
Best paying industry	Technology	-

Differences between medical claims examiner and claims benefit specialist education

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

	Medical Claims Examiner	Claims Benefit Specialist
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 40%
Most common major	Business	Business
Most common college	University of Pennsylvania	Stanford University

Medical claims examiner vs claims benefit specialist demographics

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

	Medical Claims Examiner	Claims Benefit Specialist
Average age	44	44
Gender ratio	Male, 16.6% Female, 83.4%	Male, 19.6% Female, 80.4%
Race ratio	Black 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, 11.4% Unknown, 4.4% Hispanic or Latino, 16.9% Asian, 5.2% White, 61.6% American Indian and Alaska Native, 0.5%
LGBT Percentage	10%	10%

Differences between medical claims examiner and claims benefit specialist 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.

Claims benefit specialist example responsibilities.

Analyze, process and manage FMLA claims to determine eligibility and certification in compliance with state and federal regulations.
Establish a working knowledge of CPT, ICD-9, HCPCS codes, terminology, member benefits and claim flow.
Process claims utilizing appropriate ICD-9, DSM-IV and HCPCS codes.
Analyze each claim and calculate percentages for both PPO and NON-PPO providers.
Understand CPT, HCPCS, ICD-9-CM and ICD-10-CM medical claims coding regulations and guidelines
Process Non-HMO and PPO paper and electronic claims in an accurate and time manner.

Medical claims examiner vs claims benefit specialist 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 benefit specialist skills

Customer Inquiries, 11%
Appeals, 7%
Medical Terminology, 6%
Routine Claims, 5%
CPT, 4%
Processing Issues, 4%

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Medical Claims Examiner
Medical Claims Examiner vs Claims Benefit Specialist

Updated January 8, 2025

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