Medical claims specialist vs claim specialist

The differences between medical claims specialists and claim specialists can be seen in a few details. Each job has different responsibilities and duties. While it typically takes 6-12 months to become a medical claims specialist, becoming a claim specialist takes usually requires 4-6 years. Additionally, a claim specialist has an average salary of $43,164, which is higher than the $35,706 average annual salary of a medical claims specialist.

The top three skills for a medical claims specialist include customer service, patients and medicaid. The most important skills for a claim specialist are customer service, litigation, and patients.

Medical claims specialist vs claim specialist overview

	Medical Claims Specialist	Claim Specialist
Yearly salary	$35,706	$43,164
Hourly rate	$17.17	$20.75
Growth rate	11%	-6%
Number of jobs	82,897	29,505
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 38%	Bachelor's Degree, 54%
Average age	45	44
Years of experience	12	6

What does a medical claims specialist do?

A medical claims specialist is responsible for gathering and processing the information required to complete the medical insurance claims process. Typical duties include determining covered medical insurance losses, documenting medical claims actions, and resolving claims through approval or denial of documentation. In addition, you will be responsible for maintaining excellent customer service by responding to customer inquiries and following best practices. You will also be responsible for protecting company operations by maintaining the confidentiality of information.

What does a claim specialist do?

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.

Medical claims specialist vs claim specialist salary

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

	Medical Claims Specialist	Claim Specialist
Average salary	$35,706	$43,164
Salary range	Between $28,000 And $43,000	Between $27,000 And $67,000
Highest paying City	Attleboro, MA	Newark, NJ
Highest paying state	Connecticut	New Jersey
Best paying company	Total Medical Personnel Staffing	W. R. Berkley
Best paying industry	Government	Insurance

Differences between medical claims specialist and claim specialist education

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

	Medical Claims Specialist	Claim Specialist
Most common degree	Bachelor's Degree, 38%	Bachelor's Degree, 54%
Most common major	Business	Business
Most common college	University of Pennsylvania	Stanford University

Medical claims specialist vs claim specialist demographics

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

	Medical Claims Specialist	Claim Specialist
Average age	45	44
Gender ratio	Male, 16.7% Female, 83.3%	Male, 31.0% Female, 69.0%
Race ratio	Black or African American, 9.5% Unknown, 4.2% Hispanic or Latino, 17.0% Asian, 8.3% White, 59.8% American Indian and Alaska Native, 1.3%	Black or African American, 11.4% Unknown, 4.4% Hispanic or Latino, 16.5% Asian, 5.1% White, 62.1% American Indian and Alaska Native, 0.5%
LGBT Percentage	9%	10%

Differences between medical claims specialist and claim specialist duties and responsibilities

Medical claims specialist example responsibilities.

Apply Medicare, Medicaid billing guidelines to achieve maximum reimbursement.
Detail knowledge of medical coding; ICD-9, CPT and HCPCS codes.
Confirm coverage and work with private payers, commercial payers, Medicaid, and Medicare for reimbursement of provide medical services.
Research medical records, compliance requirements and explanations of benefits to resolve accounts payable for Medicare, Medicaid and commercial insurance.
Maintain strict confidentiality/privacy of patients' protect health information in accordance with HIPAA regulations.
Assist in educating new hires in HIPPA laws and training.

Claim specialist example responsibilities.

Assist in the streamlining of EDI process to manage workflow of EDI claims.
Manage claims on desk, route/queues, and ECHS within specify turn-around-time parameters.
Manage claims, route/queues, and ECHS, within specify turn- around time parameters.
Investigate, manage, negotiate and resolve claims arising out of accidents involving automobile and homeowner policies.
Upgrade CPT-4 and ICD-9 coding procedures, staying in step with many manage care plans changing reimbursement schedules.
Manage expedition of appeals via problem solving and collaboration with other departments.

Medical claims specialist vs claim specialist skills

Common medical claims specialist skills

Customer Service, 14%
Patients, 9%
Medicaid, 7%
Medical Billing, 6%
Phone Calls, 6%
Medical Terminology, 5%

Common claim specialist skills

Customer Service, 19%
Litigation, 7%
Patients, 5%
Claims Handling, 4%
Quality Standards, 4%
Excellent Organizational, 4%

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Medical Claims Specialist
Medical Claims Specialist vs Claim Specialist

Updated January 8, 2025

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