What does a claims analyst do?
A claims analyst specializes in processing medical insurance claims. They are primarily responsible for verifying the authenticity and eligibility of claims, analyzing the billing, communicating with policyholders, and ensuring adherence to all the policies and regulations during the entire procedure. Furthermore, a claims analyst is also in charge of administrative tasks such as keeping and updating records, reaching out and sending reports to creditors, setting appointments and schedules, processing paperwork, coordinating with key personnel, and discussing terms and necessary information to clients.
Claims analyst responsibilities
Here are examples of responsibilities from real claims analyst resumes:
- Help managed meetings regarding decision making on CMS regulations.
- Process UB's and HCFA's according to guidelines.
- Analyze and investigate medical claims utilizing ICD-9 and CPT-4 coding.
- Review claims (HCFA and UB) for accurate billing submission.
- Interpret medical reports to apply appropriate ICD-9, CPT-4 and HCPCS codes for member submit claims.
- Acquire biometrics and perform phlebotomy.
- Apply payments in accordance with Medicare and cob guidelines.
- Perform Venipuncture and finger sticks as well as doing biometrics.
- Process claims for payment using ICD-9, CPT-4 and HCPS coding.
- Identify and recommend referral of potentially fraudulent claims to the SIU.
- Identify and respond to fraud indicators and assist SIU when need.
- Prepare files and run audits for Reinsurers on all books of business.
- Mail and meter all outgoing correspondence (USPS, overnight, etc . )
- Handle outgoing and incoming shipping and receiving, with various delivery services and USPS.
- Investigate and resolve suspended claims, verify diagnosis codes are code correctly (ICD-9).
Claims analyst skills and personality traits
We calculated that 14% of Claims Analysts are proficient in Customer Service, Medical Terminology, and CPT. They’re also known for soft skills such as Analytical skills, Detail oriented, and Interpersonal skills.
We break down the percentage of Claims Analysts that have these skills listed on their resume here:
- Customer Service, 14%
Implement and facilitate strategies to review for errors to inform customer service and Underwriter for planned communication and origination completion.
- Medical Terminology, 5%
Research of financial and medical terminology as well as financial documents and pharmaceuticals.
- CPT, 5%
Utilized claim systems to obtain and record claim information with ICD9 & CPT coding, reviewing to make claim payment decisions.
- Process Claims, 5%
Process claims/verify authorization requirements/coordinate benefits/follow mandates.
- Medicaid, 5%
Provided excellent customer service by reviewing Medicaid/Medicare Liens, determining auto liability, processing checks/payments/settlements/lost time from work/ worker's comp.
- Data Entry, 5%
Performed data entry which entailed working with highly sensitive military information, military claims into computer system.
Most claims analysts use their skills in "customer service," "medical terminology," and "cpt" to do their jobs. You can find more detail on essential claims analyst responsibilities here:
Analytical skills. The most essential soft skill for a claims analyst 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 claims analyst resume shows how their duties depend on analytical skills: "analyzed and processed medical insurance claims according to policies and procedures assisted members and providers in problem solving"
Detail oriented. Another soft skill that's essential for fulfilling claims analyst 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 claims analyst resume, here's how claims analysts can utilize detail oriented in their job responsibilities: "detailed knowledge of general claims processing principles, hcfa claims coding and ub-92-04 claims coding, which included all claim types. "
Interpersonal skills. Another skill that relates to the job responsibilities of claims analysts is interpersonal skills. This skill is critical to many everyday claims analyst duties, as "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." This example from a resume shows how this skill is used: "position required excellent interpersonal skills, and ability to understand and interpret policy provisions utilizing insurance codes. "
Communication skills. A commonly-found skill in claims analyst job descriptions, "communication skills" is essential to what claims analysts do. Claims analyst responsibilities rely on this skill because "claims adjusters and investigators must get information from a range of people, including claimants, witnesses, and medical experts." You can also see how claims analyst duties rely on communication skills in this resume example: "process workers compensation medical insurance claims communication with insurance recipients on verification of claims and deductibles"
The three companies that hire the most claims analysts are:
- Public Consulting Group57 claims analysts jobs
- Highmark51 claims analysts jobs
- Centene11 claims analysts jobs
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Claims analyst 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.
While similarities exist, there are also some differences between claims analysts and appraiser. For instance, claims analyst responsibilities require skills such as "medical terminology," "cpt," "process claims," and "medicaid." Whereas a appraiser is skilled in "commercial property," "appraisal reports," "mai," and "discounted cash flow." This is part of what separates the two careers.
Appraisers tend to reach similar levels of education than claims analysts. In fact, appraisers are 1.6% more likely to graduate with a Master's Degree and 0.5% less likely to have a Doctoral Degree.Claims analyst 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.
Each career also uses different skills, according to real claims analyst resumes. While claims analyst responsibilities can utilize skills like "medical terminology," "cpt," "medicaid," and "data entry," adjusters use skills like "strong customer service," "litigation," "liability claims," and "policy coverage."
Average education levels between the two professions vary. Adjusters tend to reach similar levels of education than claims analysts. In fact, they're 0.3% less likely to graduate with a Master's Degree and 0.5% less likely to earn a Doctoral Degree.What technology do you think will become more important and prevalent for Claims Analysts in the next 3-5 years?
Dr. Todd Steen
The Granger Professor of Economics, Hope College
Claims analyst vs. Insurance adjuster
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.
Some important key differences between the two careers include a few of the skills necessary to fulfill the responsibilities of each. Some examples from claims analyst resumes include skills like "medical terminology," "cpt," "process claims," and "medicaid," whereas an insurance adjuster is more likely to list skills in "insurance policies," "liability claims," "auto claims," and "catastrophe claims. "
When it comes to education, insurance adjusters tend to earn similar degree levels compared to claims analysts. In fact, they're 0.2% more likely to earn a Master's Degree, and 0.2% more likely to graduate with a Doctoral Degree.Claims analyst vs. Medical claims processor
Types of claims analyst
Updated January 8, 2025
