How to Become a Medical Claims Adjuster

Mar 11, 2020

Learn how to become a medical claims adjuster. Learn about the job description and duties, and explore the step-by-step process to start a career in medical claims adjusting.

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Should I Become a Medical Claims Adjuster?

Degree Level High school diploma or GED; bachelor's often preferred
Degree Field(s) Healthcare, medicine, or other related field
Experience Varies; 3+ years of claims experience
Licensure/Certification Licensure required in some states; voluntary certifications available
Key Skills Written and verbal communication, interpersonal, and analytical skills; familiarity with medical procedures; knowledge of medical terminology
Salary $67,540 (2018 average for medical claims adjusters, examiners, and investigators)

Sources: U.S. Bureau of Labor Statistics

Medical claims adjusters, also known as medical claims examiners, process medical claims, monitor medical bills for errors or uncovered items, negotiate bills when appropriate, and authorize the payment of medical claims. In addition, they may maintain files, watch out for fraudulent claims, and confer with patients and doctors to gather additional information when necessary. Most medical claims adjusters work for health, life, or automobile insurance companies, although there are also opportunities for self-employment. Such professionals work in office settings, handling paperwork and using computers to complete tasks. This career is not physically demanding nor does it include risk of personal injury or illness. Long hours are spent sitting, often looking at a computer screen.

There is no standard educational requirement to become a medical claims adjuster. At minimum, individuals must have a high school diploma, though having a bachelor's degree or previous field experience can open doors for prospective candidates. Licensure may also be required, depending on the state. The right skill set is particularly important, including written and verbal communication, interpersonal, and analytical skills, as well as familiarity with medical procedures and knowledge of medical terminology.

So how much do these workers earn? The U.S. Bureau of Labor Statistics reports that medical claims adjusters, examiners, and investigators earned an average yearly salary of $67,540 in May 2018.

Now that we know more about this line of work, let's take a look at how to become a medical claims adjuster.

Step 1: Get a Degree

Although it is not a strict requirement, having a bachelor's degree can provide greater job opportunities for aspiring medical claims adjusters. Relevant programs include degree programs in medicine and healthcare. Generally, aspiring medical claims adjusters should seek programs that train in medical insurance, billing, laws, and ethics. It's also wise to hone other job skills with courses in business, accounting, math, and communications.

Step 2: Gain Experience

Experience is the next step along the road to a medical claims adjuster career. According to August 2016 job listings, most employers prefer medical claims adjusters who have at least one year of previous experience in a related position. You can gain such experience in entry-level positions, such as a claims representative, nurse case manager, or insurance agent. These positions may expose workers to duties such as negotiating settlements, maintaining claims files, and evaluating cases.

Step 3: Become Licensed

Depending on the state, medical claims adjusters may need professional licensure. Some states allow claims adjusters working for large companies to work under the company's license, while other states mandate that all adjusters be individually licensed to practice. Individual licensure requirements may include a minimum age, proof of completed education, and passage of a licensing examination. Other licensure requirements include a criminal background check, fingerprints for state records, and a license fee.

Keep in mind that maintaining licensure often requires continuing education. Continuing education options may include webinars, courses, and seminars. Such continuing education can help you stay abreast of regulatory changes, advancing technologies, claims processes, and coverage policies.

Step 4: Earn Voluntary Certification

Some adjusters earn voluntary certification to demonstrate skills and increase job opportunities. Voluntary certifications and designations are available through professional claims adjuster organizations, such as the Society of Registered Professional Adjusters (RPA) and the International Claim Association (ICA). Most certifications and designations require applicants to have at least five years of experience in the field. Other requirements include passing a test and completing some continuing education credits every year.

Medical claims adjusters must have a high school diploma and licensure if required in their state, though a degree in a relevant major and certification can greatly improve job prospects.

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