Medical claims examiner vs medical claims processor

The differences between medical claims examiners and medical claims processors can be seen in a few details. Each job has different responsibilities and duties. While it typically takes 4-6 years to become a medical claims examiner, becoming a medical claims processor takes usually requires 2-4 years. Additionally, a medical claims examiner has an average salary of $42,773, which is higher than the $36,777 average annual salary of a medical claims processor.

The top three skills for a medical claims examiner include medical terminology, customer service and data entry. The most important skills for a medical claims processor are patients, healthcare, and data entry.

Medical claims examiner vs medical claims processor overview

	Medical Claims Examiner	Medical Claims Processor
Yearly salary	$42,773	$36,777
Hourly rate	$20.56	$17.68
Growth rate	-6%	-3%
Number of jobs	57,125	59,992
Job satisfaction	5	-
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 29%
Average age	44	44
Years of experience	6	4

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 medical claims processor do?

A medical claims processor has working knowledge of medical billing and coding. The qualifications for this position include knowledge of current procedural terminology (CPT) and international classification of diseases (ICD) coding systems. They are responsible for processing claims forms, adjudicating the allocation of deductibles and copays, and following through with adjudication policies to facilitate proper payment of claims.

Medical claims examiner vs medical claims processor salary

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

	Medical Claims Examiner	Medical Claims Processor
Average salary	$42,773	$36,777
Salary range	Between $30,000 And $59,000	Between $29,000 And $45,000
Highest paying City	Los Angeles, CA	Dover, DE
Highest paying state	New Jersey	Delaware
Best paying company	UST Global	Cognizant
Best paying industry	Technology	Government

Differences between medical claims examiner and medical claims processor education

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

	Medical Claims Examiner	Medical Claims Processor
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 29%
Most common major	Business	Business
Most common college	University of Pennsylvania	-

Medical claims examiner vs medical claims processor demographics

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

	Medical Claims Examiner	Medical Claims Processor
Average age	44	44
Gender ratio	Male, 16.6% Female, 83.4%	Male, 16.0% Female, 84.0%
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, 13.8% Unknown, 4.3% Hispanic or Latino, 14.4% Asian, 3.9% White, 63.2% American Indian and Alaska Native, 0.5%
LGBT Percentage	10%	11%

Differences between medical claims examiner and medical claims processor 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.

Medical claims processor example responsibilities.

Enter UB 92 and 1500 HCFA medical claims into computer system manage and process insurance claims.
Manage cases by aggressively directing the litigation process.
Submit medical claims to commercial insurance companies, Medicare, and Medicaid for payment with use of ICD-9 and CPT coding.
Review and verify patient account information against insurance program specifications, analyze surgical procedures and diagnoses using CPT-4 and ICD-9 codes.
Acknowledge and enforces confidentiality in alignment with (HIPPA) guidelines.
Audit encounters and ICD-10 codes to ensure correct coding and maximum reimbursement.

Medical claims examiner vs medical claims processor 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 medical claims processor skills

Patients, 13%
Healthcare, 10%
Data Entry, 10%
Medical Insurance Claims, 9%
Medical Terminology, 6%
Customer Service, 3%

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Medical Claims Examiner
Medical Claims Examiner vs Medical Claims Processor

Updated January 8, 2025

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