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Medical claims examiner skills for your resume and career

Updated January 8, 2025

4 min read

Below we've compiled a list of the most critical medical claims examiner skills. We ranked the top skills for medical claims examiners based on the percentage of resumes they appeared on. For example, 9.9% of medical claims examiner resumes contained medical terminology as a skill. Continue reading to find out what skills a medical claims examiner needs to be successful in the workplace.

15 medical claims examiner skills for your resume and career

1. Medical Terminology

Here's how medical claims examiners use medical terminology:

Conducted comprehensive training in health claims processing, medical terminology with anatomy and physiology, and medical billing.
Applied knowledge of medical terminology, medical billing practices and interpretation of contracts.

2. Customer Service

Customer service is the process of offering assistance to all the current and potential customers -- answering questions, fixing problems, and providing excellent service. The main goal of customer service is to build a strong relationship with the customers so that they keep coming back for more business.

Here's how medical claims examiners use customer service:

Used knowledge of products and the contractual provisions that govern administration to provide customer service to policyholders through telephone/written inquiries.
Provided customer service to policyholders and providers including information of member eligibility and benefit coverage.

3. Data Entry

Data entry means entering data into a company's system with the help of a keyboard. A person responsible for entering data may also be asked to verify the authenticity of the data being entered. A person doing data entry must pay great attention to tiny details.

Here's how medical claims examiners use data entry:

Performed data entry of insured records into database.
Performed data entry duties/research procedure and diagnosis code.

4. Medical Treatment

Here's how medical claims examiners use medical treatment:

Reviewed, interpreted, questioned and timely processed automobile medical claims and medical treatment plans for soft tissue injury PIP claims.
Managed claims, medical treatment and billing to closure of the claim or to referral to a lost time adjuster.

5. Computer System

Here's how medical claims examiners use computer system:

Processed specified medical claims on company computer system in accordance with contracted provision using established policies and procedures.
Input data into computer system accordingly.

6. Provider Contracts

The definition of a provider contract is 'an agreement between a contracting entity and a provider according to which the provider agrees to deliver medical services to a claimant under this title in exchange for payment or reimbursement of an agreed-upon amount.' A provider contract relates to exactly one business partner. It consists of a contract header and contract items and details like contract start date, contract end date, authorization group, company code for authorization checks and the number of the business partner who entered the provider contract.

Here's how medical claims examiners use provider contracts:

Verified information and authorizations on claims, reviewed new/ongoing provider contracts, completed special projects for appeals.
Analyzed and validated audit findings according to payer regulations and payer processing guidelines/provider contracts.

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7. Medicaid

Here's how medical claims examiners use medicaid:

Investigated Medicare, Medicaid and individual insurance payments in order to release benefits.
Developed knowledge of Medicaid and Medicare medical claims processing system.

8. CPT-4

Here's how medical claims examiners use cpt-4:

Processed claims under Government Contracts which required knowledge of CPT-4, ACPC, ICD9.
Experienced in ICD-9, CPT-4 coding procedure, and Citrix software applications.

9. Process Claims

Process claims refers to the procedure an insurance agent follows once receiving a claim from an insured individual. This often includes reviewing, investigating, and deciding on whether the claim will be accepted or denied depending on the results of the insurer's investigation. This is a common procedure for all kinds of insurance including medical, auto, and liability insurance.

Here's how medical claims examiners use process claims:

Review and process claims for approve eligibility benefits.
Process claims based on Division of Financial Responsibility.

10. ICD-9

Here's how medical claims examiners use icd-9:

Verified that all ICD-9, CPT, modifiers and revenue codes were used correctly, prior to payment approval.
Processed medical & hospital claims utilizing the proper CPT, ICD-9 code, DRG and procedure codes.

11. CMS

A Content Management System or CMS is computer software that works as a framework where content can be assembled and managed by using a database. CMS is an important asset in web development. This platform enables users to create, edit, collaborate on, publish and store digital content. It helps users to manage their content and modify it from a single system.

Here's how medical claims examiners use cms:

Used supportive documents and medical information to determine payment or denial of services based on CMS regulations and medical policies.
Process and data enter CMS - 1500's and UB 92's in relational database system.

12. Denial Letters

Here's how medical claims examiners use denial letters:

Handled annual performance reviews, claim denial letters, surgery pre-determination letters, and insurance commissioner complaints.

13. HIPAA

Here's how medical claims examiners use hipaa:

Safeguarded confidential information per HIPAA laws.
Supported Health Care Providers with Benefit inquiries, Claim issues, Remittance information, and Eligibility, while following HIPAA guidelines.

14. HCPCS

Here's how medical claims examiners use hcpcs:

Verify all member and provider information is correct and also make sure all HCPCS codes are correct
Check HCPCS codes to make sure that the correct code is billed for the correct service.

15. Fee Schedules

Here's how medical claims examiners use fee schedules:

Assisted claims examiners with information regarding procedures codes, diagnosis codes and fee schedules or complex claims.
Verified medical benefits such as deductibles, co-insurance, stop loss, and fee schedules.

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List of medical claims examiner skills to add to your resume

The most important skills for a medical claims examiner resume and required skills for a medical claims examiner to have include:

Medical Terminology
Customer Service
Data Entry
Medical Treatment
Computer System
Provider Contracts
Medicaid
CPT-4
Process Claims
ICD-9
CMS
Denial Letters
HIPAA
HCPCS
Fee Schedules
Adjudicate Claims
Medical Bills

Medical Insurance Claims
HMO
DRG
Dental Claims
COB
UB
Legal Compliance
Claims Examiners
HCFA
Insurance Coverage
PPO
Quality Standards
Medical Documentation
Hippa
EDI
Questionable Claims
Policy Provisions

Hospital Claims
Procedure Codes
EOB
Medical Necessity
Pending Claims
POS
Diagnosis Codes
DME
Insurance Benefits
Medi-Cal
Production Standards
Customer Inquiries
Health Claims
Facets
Health Plan
Ub04

Updated January 8, 2025

Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

Updated January 8, 2025

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