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 processor responsibilities
Here are examples of responsibilities from real medical claims processor resumes:
- 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.
- Train in fraudulent claims, patient privacy and confidentiality in accordance with HIPPA regulations.
- Conduct research online with several Medicare HMO carriers to obtain payments on claim items.
- Pay institutional/UB92 and HCFA claims base on client groups contractual agreement, and/or health plans reciprocity rates.
- Correspond letters, send out claim forms, EOB's, checks to providers, and medical facilities.
- Respond to customer inquiries following HIPAA rules and solve payment discrepancies using detail knowledge of multiple plan policies.
- Work closely with CEO on analyzing financial reports for weekly and monthly HMO payments, denials and outstanding balances
- Produce and review the finalized EOB s before issuing to the appropriate insured/claimant, provider, and/or insurance carrier.
- Process reimbursement to vendors also veterans.
- Submit Medicare and Medicaid claims electronically for payments.
Medical claims processor skills and personality traits
We calculated that 13% of Medical Claims Processors are proficient in Patients, Healthcare, and Data Entry. They’re also known for soft skills such as Organizational skills, Communication skills, and Math skills.
We break down the percentage of Medical Claims Processors that have these skills listed on their resume here:
- Patients, 13%
Demonstrated extensive, amicable telephone communication with patients and medical facilities to obtain and supply necessary information.
- Healthcare, 10%
Prepare Medical Claims to be processed and pay Healthcare Claims for Veterans on behalf of the VA health facilities.
- Data Entry, 10%
Performed accurate coding and data entry of medical and dental information provided by medical facilities.
- Medical Insurance Claims, 9%
Processed secondary medical insurance claims in accordance to coordination of benefit rules of Medicaid and Medicare.
- Medical Terminology, 6%
Position requires in depth knowledge of medical terminology which is useful in reading medical reports and determining coverage.
- Customer Service, 3%
Resolve policyholder's questions regarding policy benefits and payment and consistently provide excellent customer service on all inquiries received.
"patients," "healthcare," and "data entry" are among the most common skills that medical claims processors use at work. You can find even more medical claims processor responsibilities below, including:
Organizational skills. One of the key soft skills for a medical claims processor to have is organizational skills. You can see how this relates to what medical claims processors do because "financial clerks must be able to arrange files so they can find them quickly and efficiently." Additionally, a medical claims processor resume shows how medical claims processors use organizational skills: "maintain quality financial claims service by following corporate customer service practices and organizational standards. "
Communication skills. Another soft skill that's essential for fulfilling medical claims processor duties is communication skills. The role rewards competence in this skill because "financial clerks should be able to explain policies and procedures to colleagues and customers." According to a medical claims processor resume, here's how medical claims processors can utilize communication skills in their job responsibilities: "required highest standard of written communication and data entry. "
Math skills. Another skill that relates to the job responsibilities of medical claims processors is math skills. This skill is critical to many everyday medical claims processor duties, as "the job duties of financial clerks includes calculating charges and updating financial records." This example from a resume shows how this skill is used: "coded dental claims for reimbursable payments to doctors and insurance carriers cut weekly checks, and maintained reports and statistics. "
The three companies that hire the most medical claims processors are:
- Sedgwick LLP88 medical claims processors jobs
- Quest Diagnostics6 medical claims processors jobs
- Ciox Health4 medical claims processors jobs
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Compare different medical claims processors
Medical claims processor vs. Billing representative
A billing representative assists with the overall operations of the organization's billing department. Billing representatives post payments timely on the database, update account statements, generate financial reports, release invoices, and resolve account discrepancies. They also perform client accounts reconciliation as needed, monitor account receivables, review overdated balance, and notify clients of payment updates to ensure accurate and timely billing. A billing representative must have strong analytical and communication skills to manage clients' accounts, as well as comprehensive knowledge on the accounting industry to explain the payment terms and policies of an organization to a client.
These skill sets are where the common ground ends though. The responsibilities of a medical claims processor are more likely to require skills like "healthcare," "medical insurance claims," "cpt-4," and "process claims." On the other hand, a job as a billing representative requires skills like "medical billing," "cpt," "appeals," and "medical claims." As you can see, what employees do in each career varies considerably.
Billing representatives tend to make the most money working in the technology industry, where they earn an average salary of $35,295. In contrast, medical claims processors make the biggest average salary, $42,406, in the government industry.The education levels that billing representatives earn slightly differ from medical claims processors. In particular, billing representatives are 0.2% less likely to graduate with a Master's Degree than a medical claims processor. Additionally, they're 0.1% less likely to earn a Doctoral Degree.Medical claims processor vs. Insurance clerk
An insurance clerk usually works to process insurance, reinstatement, changes, or cancellations for a company or an individual account. They are responsible for monitoring, processing, and organizing different insurance claims for a client. They usually work closely with the company's insurance agent to provide necessary information to process the clients' application. This career requires a broad knowledge of local and state insurance policies, good attention to detail, excellent communication skills, customer service skills, and administrative skills.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that medical claims processor responsibilities requires skills like "healthcare," "cpt-4," "process claims," and "hcpcs." But an insurance clerk might use other skills in their typical duties, such as, "patient insurance," "medicare," "scheduling appointments," and "insurance forms."
On average, insurance clerks earn a lower salary than medical claims processors. Some industries support higher salaries in each profession. Interestingly enough, insurance clerks earn the most pay in the finance industry with an average salary of $33,939. Whereas medical claims processors have higher pay in the government industry, with an average salary of $42,406.insurance clerks earn similar levels of education than medical claims processors in general. They're 0.4% less likely to graduate with a Master's Degree and 0.1% less likely to earn a Doctoral Degree.Medical claims processor vs. Insurance coordinator
An insurance coordinator is responsible for evaluating and validating insurance information to verify claims and process the necessary claims resolutions for parties. Insurance coordinators submit claims statements timely to the insurance officers for review, coordinate with the clients for inquiries and updates, and reach out to medical institutions for accurate filing of payments. An insurance coordinator must have excellent communication and analytical skills to assess reports, resolve claims discrepancies, and escalate high-level complaints to the officers for immediate action.
Some important key differences between the two careers include a few of the skills necessary to fulfill the responsibilities of each. Some examples from medical claims processor resumes include skills like "healthcare," "medical insurance claims," "cpt-4," and "process claims," whereas an insurance coordinator is more likely to list skills in "strong customer service," "insurance eligibility," "health insurance," and "medical billing. "
Insurance coordinators earn the highest salary when working in the pharmaceutical industry, where they receive an average salary of $33,609. Comparatively, medical claims processors have the highest earning potential in the government industry, with an average salary of $42,406.insurance coordinators typically earn similar educational levels compared to medical claims processors. Specifically, they're 1.0% more likely to graduate with a Master's Degree, and 0.1% more likely to earn a Doctoral Degree.Medical claims processor vs. Insurance specialist
An insurance specialist is an individual responsible for interpreting insurance plans and providing risk management advice to clients and wealth managers. Insurance specialists must have a full understanding of risk management to craft a comprehensive solution that integrates well with the client's portfolio. They need to manage their clients' accounts and should maintain contact with clients after the application process. Insurance specialists must ensure that government insurance programs comply with federal laws, regulations, and contracts within the healthcare industry.
Even though a few skill sets overlap between medical claims processors and insurance specialists, there are some differences that are important to note. For one, a medical claims processor might have more use for skills like "healthcare," "medical insurance claims," "cpt-4," and "process claims." Meanwhile, some responsibilities of insurance specialists require skills like "exceptional client," "life insurance," "health insurance," and "insurance claims. "
In general, insurance specialists earn the most working in the government industry, with an average salary of $38,343. The highest-paying industry for a medical claims processor is the government industry.insurance specialists reach similar levels of education compared to medical claims processors, in general. The difference is that they're 1.8% more likely to earn a Master's Degree, and 0.2% more likely to graduate with a Doctoral Degree.Types of medical claims processor
Updated January 8, 2025
