What Does a Claim Processor Do? Roles And Responsibilities

Updated March 14, 2024

7 min read

A Claims Processor is responsible for processing and verifying insurance claims, in adherence to the policies, laws, and regulations of the company involved. Aside from examining its authenticity, they must also oversee new policies and recommend modifications should it be needed. Moreover, it is also the task of the Claims Processor to prepare the necessary documents and guidelines for the policyholder, process reimbursem*nts upon approval, provide answers to inquiries, and report issues and updates to the management.

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Claim processor responsibilities

Claim processors verify information, conduct research, and update accounts. They ensure eligibility and apply policy endorsem*nts and exclusions. They also coordinate benefits with other insurance carriers. They investigate, evaluate, and negotiate property damage and bodily injury settlements. They review medical claims and determine medical necessity, coverage benefits, and discrepancies. They resolve all unprecedented claims issues and establish a process for documenting resolution procedures.

Here are examples of responsibilities from real claim processor resumes:

Experience in many facets of the managed healthcare insurance business.
Manage claims, route/queues, and ECHS, within specify turn- around time parameters.
Use ICD-9, CPT-4 and other medical manuals to adjudicate claims.
Analyze claims submit by providers and facilities for appropriate ICD-9, CPT and HCPCS codes against charges that are being bill.
Call DME and HME companies to correct invoices.
Coach and assist in the training of new EMR databases.
Look up DRG rates for inpatient claims bill on UB-92 form.
Pull documents request from the EMR system to be mail or fax.
Start off as a claim processor and quickly become promoted to Sr.
Used CPT-4 code for medical procedures and service, also coding and collections.
Process DME claims (electronically and on paper) according to Medicare guidelines.
Work on getting the system transfer over to start using the new ICD-10 codes.
Subject matter expert on claims regulatory requirements, including AB1455, Medi-Cal, and Medicare.
Check HCPCS codes to make sure that the correct code is billed for the correct service.
Interact with field staff, attorneys, nurse case managers, medical providers, and TPA.

Claim processor skills and personality traits

We calculated that 20% of Claim Processors are proficient in Customer Service, Data Entry, and Medical Terminology. They’re also known for soft skills such as Interpersonal skills, Analytical skills, and Detail oriented.

We break down the percentage of Claim Processors that have these skills listed on their resume here:

Customer Service, 20%
Provided customer service to claimants by greeting and interviewing individuals to determine if they met the qualifications and eligibility for funding.
Data Entry, 8%
Conducted accurate review, processing medical claims, performing compliant data entry, adhering to established procedures and productivity requirements.
Medical Terminology, 5%
Analyzed surgery claims utilizing prior health care knowledge such as medical terminology, surgery guidelines and overall claims processing procedures.
CPT, 5%
Maximized reimbursem*nt by ensuring accurate CPT and Diagnosis Codes.
Claims Processing, 4%
Led specialty units including high-risk management and quality assurance and drafted initial training and policy manuals for specialty claims processing units.
Medical Insurance Claims, 4%
Maintained a high level of productivity and accuracy during acquisition of 100,000 major medical insurance claims from previous insurance carriers.

Common skills that a claim processor uses to do their job include "customer service," "data entry," and "medical terminology." You can find details on the most important claim processor responsibilities below.

Interpersonal skills. The most essential soft skill for a claim processor to carry out their responsibilities is interpersonal skills. This skill is important for the role 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." Additionally, a claim processor resume shows how their duties depend on interpersonal skills: "position required excellent interpersonal skills, and ability to understand and interpret policy provisions utilizing insurance codes. "

Analytical skills. Many claim processor duties rely on analytical skills. "adjusters and examiners must each evaluate whether the insurance company is obligated to pay a claim and determine the amount to pay," so a claim processor will need this skill often in their role. This resume example is just one of many ways claim processor responsibilities rely on analytical skills: "categorized, indexed, and distributed hcfa forms, ub forms, clinical records and information to the database. "

Detail oriented. Another skill that relates to the job responsibilities of claim processors is detail oriented. This skill is critical to many everyday claim processor duties, as "adjusters, appraisers, examiners, and investigators must carefully review documents and damaged property, because small details can have large financial consequences." This example from a resume shows how this skill is used: "received detail training on hcfa 1500 and ub04 claims processing and cpt code icd9 training. "

Communication skills. A big part of what claim processors do relies on "communication skills." You can see how essential it is to claim processor 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 claim processor tasks: "facilitated process improvement initiatives in the level of communication, connectivity and understanding between on-site and off-site sedgwick cms employees. "

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Claim processor vs. 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.

We looked at the average claim processor salary and compared it with the wages of an adjuster. Generally speaking, adjusters are paid $8,195 higher than claim processors per year.While their salaries may differ, the common ground between claim processors and adjusters are a few of the skills required in each roleacirc;euro;trade;s responsibilities. In both careers, employee duties involve skills like customer service, excellent negotiation, and auto claims.

While similarities exist, there are also some differences between claim processors and adjuster. For instance, claim processor responsibilities require skills such as "data entry," "medical terminology," "cpt," and "claims processing." Whereas a adjuster is skilled in "strong customer service," "litigation," "liability claims," and "policy coverage." This is part of what separates the two careers.

adjusters really shine in the insurance industry with an average salary of $50,894. Comparatively, claim processors tend to make the most money in the insurance industry with an average salary of $47,078.adjusters tend to reach similar levels of education than claim processors. In fact, adjusters are 1.3% more likely to graduate with a Master's Degree and 0.5% more likely to have a Doctoral Degree.

Claim processor vs. Appraiser

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.

On average, appraisers earn a $1,022 higher salary than claim processors a year.A few skills overlap for claim processors and appraisers. Resumes from both professions show that the duties of each career rely on skills like "customer service," "claims handling," and "commercial property. "

Each career also uses different skills, according to real claim processor resumes. While claim processor responsibilities can utilize skills like "data entry," "medical terminology," "cpt," and "claims processing," appraisers use skills like "appraisal reports," "mai," "discounted cash flow," and "market research."

appraisers earn a higher average salary than claim processors. But appraisers earn the highest pay in the insurance industry, with an average salary of $48,145. Additionally, claim processors earn the highest salaries in the insurance with average pay of $47,078 annually.appraisers earn similar levels of education than claim processors in general. They're 3.2% more likely to graduate with a Master's Degree and 0.5% more likely to earn a Doctoral Degree.

Claim processor vs. Reimbursem*nt specialist

A reimbursem*nt specialist is responsible for analyzing insurance documents, processing reimbursem*nt claims, and releasing accurate billing statements for insurance claims. Reimbursem*nt specialists must have excellent analytical skills, especially on performing clerical tasks to evaluate insurance cases, investigate cases, and update the account information of the clients on the database. They should also have impeccable communication skills and understanding of the insurance processes to be able to coordinate with the clients, explaining the procedures of their claims accurately, and coordinate with the insurance management to improve the claims processes.

On average, reimbursem*nt specialists earn lower salaries than claim processors, with a $2,928 difference per year.Using the responsibilities included on claim processors and reimbursem*nt specialists resumes, we found that both professions have similar skill requirements, such as "customer service," "data entry," and "medical terminology.rdquo;

The required skills of the two careers differ considerably. For example, claim processors are more likely to have skills like "claims processing," "medical insurance claims," "provider contracts," and "quality standards." But a reimbursem*nt specialist is more likely to have skills like "patients," "appeals," "medicare," and "patient accounts."

reimbursem*nt specialists earn the highest salary when working in the pharmaceutical industry, where they receive an average salary of $41,366. Comparatively, claim processors have the highest earning potential in the insurance industry, with an average salary of $47,078.reimbursem*nt specialists typically earn similar educational levels compared to claim processors. Specifically, they're 0.6% more likely to graduate with a Master's Degree, and 0.5% more likely to earn a Doctoral Degree.

Claim processor vs. Provider services representative

A provider services representative is responsible for supporting, developing, and maintaining service relationships with involved participants, including providers, physicians, and administrators. Your duties typically include responding to direct and electronic questions from clients about rates, policies, referrals, and eligibility, handling telephone calls for the provider and member inquiries, and resolving complaints by the member and member representative. In addition, you will be assisting in collecting supporting data and documentation about the member's care. You are also expected to conduct research to be able to provide a well-informed answer to members' inquiries.

Provider services representatives average a lower salary than the annual salary of claim processors. The difference is about $7,343 per year.While their salaries may vary, claim processors and provider services representatives both use similar skills to perform their duties. Resumes from both professions include skills like "customer service," "data entry," and "medical terminology. "While some skills are required in each professionacirc;euro;trade;s responsibilities, there are some differences to note. "medical insurance claims," "excellent negotiation," "adjudicate claims," and "property damage" are skills that commonly show up on claim processor resumes. On the other hand, provider services representatives use skills like patients, health insurance, appeals, and fee schedules on their resumes.provider services representatives enjoy the best pay in the health care industry, with an average salary of $34,112. For comparison, claim processors earn the highest salary in the insurance industry.In general, provider services representatives hold similar degree levels compared to claim processors. Provider services representatives are 0.8% more likely to earn their Master's Degree and 0.4% less likely to graduate with a Doctoral Degree.

Types of claim processor

3-6 monthsProcessorAverage Salary: $32,098Bachelor's DegreeAvailable Jobs: 57,025
4-6 yearsClaims RepresentativeAverage Salary: $38,796Bachelor's DegreeAvailable Jobs: 22,760
4-6 yearsClaims AnalystAverage Salary: $48,398Bachelor's DegreeAvailable Jobs: 11,310
2-4 yearsAdjusterAverage Salary: $49,396Bachelor's DegreeAvailable Jobs: 9,272
1-2 yearsProvider Services RepresentativeAverage Salary: $33,858Bachelor's DegreeAvailable Jobs: 4,926
2-4 yearsAppraiserAverage Salary: $42,223Bachelor's DegreeAvailable Jobs: 4,482

Updated March 14, 2024

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.

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Claim Processor Related Careers

Adjuster
Appraiser
Auto Claims Adjuster
Claim Specialist
Claims Analyst
Claims Benefit Specialist
Claims Coordinator
Claims Representative
Claims Supervisor
Insurance Adjuster
Medical Claims Analyst
Medical Claims Examiner
Medical Claims Processor
Processor
Provider Services Representative

Claim Processor Related Jobs

Adjuster
Appraiser
Auto Claims Adjuster
Claim Specialist
Claims Analyst
Claims Benefit Specialist
Claims Coordinator
Claims Representative
Claims Supervisor
Insurance Adjuster
Medical Claims Analyst
Medical Claims Examiner
Medical Claims Processor
Processor
Provider Services Representative

Claim Processor Jobs By Location

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What Does a Claim Processor Do? Roles And Responsibilities - Zippia (2024)