Medical claims examiner vs claims representative

The differences between medical claims examiners 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 examiner and a claims representative. Additionally, a medical claims examiner has an average salary of $42,773, which is higher than the $38,796 average annual salary of a claims representative.

The top three skills for a medical claims examiner include medical terminology, customer service and data entry. The most important skills for a claims representative are customer service, quality standards, and policy coverage.

Medical claims examiner vs claims representative overview

	Medical Claims Examiner	Claims Representative
Yearly salary	$42,773	$38,796
Hourly rate	$20.56	$18.65
Growth rate	-6%	-6%
Number of jobs	57,125	18,565
Job satisfaction	5	-
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 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 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 examiner vs claims representative salary

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

	Medical Claims Examiner	Claims Representative
Average salary	$42,773	$38,796
Salary range	Between $30,000 And $59,000	Between $28,000 And $53,000
Highest paying City	Los Angeles, CA	Dearborn, MI
Highest paying state	New Jersey	New Jersey
Best paying company	UST Global	W. R. Berkley
Best paying industry	Technology	Government

Differences between medical claims examiner and claims representative education

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

	Medical Claims Examiner	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 examiner vs claims representative demographics

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

	Medical Claims Examiner	Claims Representative
Average age	44	44
Gender ratio	Male, 16.6% Female, 83.4%	Male, 37.5% Female, 62.5%
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, 11.0% 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 examiner and claims representative 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 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 examiner vs claims representative 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 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 Examiner
Medical Claims Examiner vs Claims Representative

Updated January 8, 2025

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