Medical claims examiner vs senior claims specialist

The differences between medical claims examiners and senior claims 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 senior claims specialist. Additionally, a senior claims specialist has an average salary of $69,808, 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 senior claims specialist are customer service, litigation, and claims handling.

Medical claims examiner vs senior claims specialist overview

	Medical Claims Examiner	Senior Claims Specialist
Yearly salary	$42,773	$69,808
Hourly rate	$20.56	$33.56
Growth rate	-6%	-6%
Number of jobs	57,125	11,011
Job satisfaction	5	-
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 65%
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 senior claims specialist do?

A senior claims specialist's role is to handle and process insurance claims, ensuring accuracy and smooth workflow. Their responsibilities include liaising with clients to identify their needs, reviewing and validating documentation, resolving issues and concerns, and traveling to different locations in order to perform claims inspections and investigations for client eligibility. They may also approve claims applications and negotiate settlements. Furthermore, as a senior claims specialist, it is essential to lead and serve as a mentor to junior specialists, all while implementing the company's policies and regulations.

Medical claims examiner vs senior claims specialist salary

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

	Medical Claims Examiner	Senior Claims Specialist
Average salary	$42,773	$69,808
Salary range	Between $30,000 And $59,000	Between $45,000 And $107,000
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 senior claims specialist education

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

	Medical Claims Examiner	Senior Claims Specialist
Most common degree	Bachelor's Degree, 36%	Bachelor's Degree, 65%
Most common major	Business	Business
Most common college	University of Pennsylvania	Stanford University

Medical claims examiner vs senior claims specialist demographics

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

	Medical Claims Examiner	Senior Claims Specialist
Average age	44	44
Gender ratio	Male, 16.6% Female, 83.4%	Male, 40.7% Female, 59.3%
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, 12.0% Unknown, 4.4% Hispanic or Latino, 16.8% Asian, 5.2% White, 61.0% American Indian and Alaska Native, 0.5%
LGBT Percentage	10%	10%

Differences between medical claims examiner and senior claims 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.

Senior claims specialist example responsibilities.

Manage assigned third party administration (TPA) multi-jurisdictional workers' compensation; subrogation recovery claims; assign defense attorney.
Work toward settlement with claimants and attorneys, or determine company litigation strategy, participating in mediation and arbitration when necessary.
Maintain EDI processing table logic.
Work with testing HIPAA transactions, reporting and processing data reporting to the state.
Review data entry of claims receive through the EDI system for accuracy prior to processing.
Operate within all company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines.

Medical claims examiner vs senior claims 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 senior claims specialist skills

Customer Service, 26%
Litigation, 10%
Claims Handling, 8%
SR, 5%
Settlement Conferences, 5%
Excellent Interpersonal, 4%

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Medical Claims Examiner
Medical Claims Examiner vs Senior Claims Specialist

Updated January 8, 2025

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