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.
Medical claims examiner responsibilities
Here are examples of responsibilities from real medical claims examiner resumes:
- 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.
- Used supportive documents and medical information to determine payment or denial of services base on CMS regulations and medical policies.
- Experience with Medicare, Medicaid and commercial insurance coordination of benefits.
- Investigate Medicare, Medicaid and individual insurance payments in order to release benefits.
- Prepare deposition and medical records summaries along with exhibits and other case-relate materials for medical malpractice litigation.
- Examine and adjudicate initial entitlement claims for retirement, supplemental, and relate disability annuities.
Medical claims examiner skills and personality traits
We calculated that 10% of Medical Claims Examiners are proficient in Medical Terminology, Customer Service, and Data Entry. They’re also known for soft skills such as Analytical skills, Detail oriented, and Interpersonal skills.
We break down the percentage of Medical Claims Examiners that have these skills listed on their resume here:
- Medical Terminology, 10%
Conducted comprehensive training in health claims processing, medical terminology with anatomy and physiology, and medical billing.
- Customer Service, 9%
Used knowledge of products and the contractual provisions that govern administration to provide customer service to policyholders through telephone/written inquiries.
- Data Entry, 7%
Performed data entry of insured records into database.
- Medical Treatment, 5%
Reviewed, interpreted, questioned and timely processed automobile medical claims and medical treatment plans for soft tissue injury PIP claims.
- Computer System, 5%
Processed specified medical claims on company computer system in accordance with contracted provision using established policies and procedures.
- Provider Contracts, 4%
Verified information and authorizations on claims, reviewed new/ongoing provider contracts, completed special projects for appeals.
Most medical claims examiners use their skills in "medical terminology," "customer service," and "data entry" to do their jobs. You can find more detail on essential medical claims examiner responsibilities here:
Analytical skills. The most essential soft skill for a medical claims examiner to carry out their responsibilities is analytical skills. This skill is important for the role because "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay." Additionally, a medical claims examiner resume shows how their duties depend on analytical skills: "verify and analyze data used in processing hcfa and ub92 forms. "
Detail oriented. Another soft skill that's essential for fulfilling medical claims examiner duties is detail oriented. The role rewards competence in this skill because "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." According to a medical claims examiner resume, here's how medical claims examiners can utilize detail oriented in their job responsibilities: "reviewed medical insurance claims and determined benefits based on policy specific details* adjudicated an average of 100 claims per day. "
Interpersonal skills. medical claims examiners are also known for interpersonal skills, which are critical to their duties. You can see how this skill relates to medical claims examiner responsibilities, because "adjusters, examiners, and investigators often meet with claimants and others who may be upset by the situation that requires a claim or by the settlement the company is offering." A medical claims examiner resume example shows how interpersonal skills is used in the workplace: "position required excellent interpersonal skills, and ability to understand and interpret policy provisions utilizing insurance codes. "
Communication skills. A big part of what medical claims examiners do relies on "communication skills." You can see how essential it is to medical claims examiner responsibilities because "claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts." Here's an example of how this skill is used from a resume that represents typical medical claims examiner tasks: "direct communication with health care providers and other insurance companies to gather cob data;. "
The three companies that hire the most medical claims examiners are:
- Robert Half5 medical claims examiners jobs
- Texas Children's Hospital2 medical claims examiners jobs
- International Medical Group2 medical claims examiners jobs
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Compare different medical claims examiners
Medical claims examiner vs. Insurance adjuster
An adjuster is responsible for evaluating the extent of loss in the company by calculating the damage costs, determining the settlement payment to the client, and managing the reputation of the company for claims accountability. Adjusters must have extensive knowledge of the insurance principles and processes, following the state and federal regulations to protect clients and the business from insurance fraud. They collect documents from different organizations, perform field research, and interview witnesses to verify the accuracy of claims statement.
While similarities exist, there are also some differences between medical claims examiners and insurance adjuster. For instance, medical claims examiner responsibilities require skills such as "medical terminology," "data entry," "medical treatment," and "computer system." Whereas a insurance adjuster is skilled in "insurance policies," "liability claims," "auto claims," and "catastrophe claims." This is part of what separates the two careers.
Insurance adjusters earn the highest salaries when working in the insurance industry, with an average yearly salary of $60,583. On the other hand, medical claims examiners are paid more in the technology industry with an average salary of $52,782.The education levels that insurance adjusters earn slightly differ from medical claims examiners. In particular, insurance adjusters are 2.8% more likely to graduate with a Master's Degree than a medical claims examiner. Additionally, they're 1.4% more likely to earn a Doctoral Degree.Medical claims examiner vs. Adjuster
A claims specialist is responsible for processing insurance claims, reviewing insurance coverage, and analyzing claims cases. Claims specialists' duties include negotiating claims settlements, validating claims to prevent fraud, creating court testimonies as needed, developing claim review plans, and checking necessary documents and related resolve claims. A claims specialist must have strong analytical and critical-thinking skills to authorize claim payment and investigate complex and unusual claims. Claims specialists should also have extensive knowledge of the insurance processes to handle various cases, following legal policies and regulatory procedures.
In addition to the difference in salary, there are some other key differences worth noting. For example, medical claims examiner responsibilities are more likely to require skills like "medical terminology," "data entry," "computer system," and "provider contracts." Meanwhile, an adjuster has duties that require skills in areas such as "strong customer service," "litigation," "liability claims," and "policy coverage." These differences highlight just how different the day-to-day in each role looks.
Adjusters earn a higher average salary than medical claims examiners. But adjusters earn the highest pay in the insurance industry, with an average salary of $50,894. Additionally, medical claims examiners earn the highest salaries in the technology with average pay of $52,782 annually.adjusters earn similar levels of education than medical claims examiners in general. They're 2.3% more likely to graduate with a Master's Degree and 1.4% more likely to earn a Doctoral Degree.Medical claims examiner vs. Claim specialist
An appraiser is someone who assesses the monetary value of a property such as an automobile, real property, and personal claim. His/Her or her responsibilities include resolving disparities between a property's monetary values and preparing narrative reports for projects. The essential skills that an appraiser should possess to accomplish such responsibilities include a keen eye for details, strong communication, analytical, and problem-solving skills, and the ability to work under pressure. The education requirements for the job vary depending on the area of focus.
There are many key differences between these two careers, including some of the skills required to perform responsibilities within each role. For example, a medical claims examiner is likely to be skilled in "medical treatment," "provider contracts," "cpt-4," and "process claims," while a typical claim specialist is skilled in "litigation," "patients," "excellent organizational," and "excellent interpersonal."
Claim specialists earn the best pay in the insurance industry, where they command an average salary of $56,779. Medical claims examiners earn the highest pay from the technology industry, with an average salary of $52,782.When it comes to education, claim specialists tend to earn similar degree levels compared to medical claims examiners. In fact, they're 2.1% more likely to earn a Master's Degree, and 0.8% more likely to graduate with a Doctoral Degree.Medical claims examiner vs. Appraiser
Even though a few skill sets overlap between medical claims examiners and appraisers, there are some differences that are important to note. For one, a medical claims examiner might have more use for skills like "medical terminology," "data entry," "medical treatment," and "computer system." Meanwhile, some responsibilities of appraisers require skills like "commercial property," "appraisal reports," "mai," and "discounted cash flow. "
The insurance industry tends to pay the highest salaries for appraisers, with average annual pay of $48,145. Comparatively, the highest medical claims examiner annual salary comes from the technology industry.In general, appraisers hold similar degree levels compared to medical claims examiners. Appraisers are 4.2% more likely to earn their Master's Degree and 0.7% more likely to graduate with a Doctoral Degree.Types of medical claims examiner
Updated January 8, 2025
