Medical claims specialist vs medical claims processor

The differences between medical claims specialists and medical claims processors 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 medical claims processor takes usually requires 2-4 years. Additionally, a medical claims processor has an average salary of $36,777, 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 medical claims processor are patients, healthcare, and data entry.

Medical claims specialist vs medical claims processor overview

	Medical Claims Specialist	Medical Claims Processor
Yearly salary	$35,706	$36,777
Hourly rate	$17.17	$17.68
Growth rate	11%	-3%
Number of jobs	82,897	59,992
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 38%	Bachelor's Degree, 29%
Average age	45	44
Years of experience	12	4

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 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 specialist vs medical claims processor salary

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

	Medical Claims Specialist	Medical Claims Processor
Average salary	$35,706	$36,777
Salary range	Between $28,000 And $43,000	Between $29,000 And $45,000
Highest paying City	Attleboro, MA	Dover, DE
Highest paying state	Connecticut	Delaware
Best paying company	Total Medical Personnel Staffing	Cognizant
Best paying industry	Government	Government

Differences between medical claims specialist and medical claims processor education

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

	Medical Claims Specialist	Medical Claims Processor
Most common degree	Bachelor's Degree, 38%	Bachelor's Degree, 29%
Most common major	Business	Business
Most common college	University of Pennsylvania	-

Medical claims specialist vs medical claims processor demographics

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

	Medical Claims Specialist	Medical Claims Processor
Average age	45	44
Gender ratio	Male, 16.7% Female, 83.3%	Male, 16.0% Female, 84.0%
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, 13.8% Unknown, 4.3% Hispanic or Latino, 14.4% Asian, 3.9% White, 63.2% American Indian and Alaska Native, 0.5%
LGBT Percentage	9%	11%

Differences between medical claims specialist and medical claims processor 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.

Medical claims processor example responsibilities.

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.

Medical claims specialist vs medical claims processor skills

Common medical claims specialist skills

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

Common medical claims processor skills

Patients, 13%
Healthcare, 10%
Data Entry, 10%
Medical Insurance Claims, 9%
Medical Terminology, 6%
Customer Service, 3%

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Medical Claims Specialist
Medical Claims Specialist vs Medical Claims Processor

Updated January 8, 2025

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