Medical Claims Examiner: Employment Info & Requirements

Mar 25, 2019

Acting as the insurers of insurance companies, medical claims examiners vet all health insurance claims submitted by patients, making sure the information is accurate, and all guidelines have been followed before approving payments. Read on for the details of this career to see if it's the right one for you.

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Career Definition for a Medical Claims Examiner

A career in medical claims examination might be a good choice for detail-oriented individuals with excellent administrative skills and knowledge of medical terminology. Usually working for health insurance companies, medical claims examiners are responsible for reviewing all insurance claims to ensure information integrity, adherence to standard guidelines and timeliness of processing. Depending on their appraisal of the claim, medical claims examiners then approve payment or facilitate further investigation.

Education Employers may look for a high school diploma or bachelor's degree
Job Skills Detail orientation, knowledge of medical terminology, good judgment, integrity, understanding of health insurance administration processes
Median Salary(2017)* $64,900 for all claims adjusters, investigators and examiners
Job Outlook(2016-2026)* 1% increase for all claims adjusters, investigators and examiners

Source: *U.S. Bureau of Labor Statistics

Required Education

There are no standard educational requirements for medical claims examiners, but most employers require a high school diploma and some look for a bachelor's degree, preferably in a medical discipline or life science. With some work experience, ambitious medical claims examiners may pursue certification by the International Claim Association (ICA), which administers two levels of coursework and certifying examinations. The Associate, Life and Health Claims (ALHC) Program requires six courses that cover the administration of health insurance claims, and the Fellow, Life and Health Claims (FLHC) Program, which may be undertaken after earning the ALHC designation, requires four additional courses. Such certifications are not obligatory, but they can broaden a medical claims examiner's career prospects.

Skills Required

Medical claims examiners must be extremely detail-oriented, precise and thorough. Knowledge of medical terminology is a must, as is a broad understanding of health insurance administration processes and standard guidelines, such as the average hospital stay for certain procedures or standard treatments for common illnesses. Medical claims examiners must possess good judgment and integrity, as their review of an insurance claim acts as the final approval of payout and the ultimate determinant of cost to the insurance company.

Career Outlook

According to the U.S. Bureau of Labor Statistics (BLS), medical claims examiners usually specialize in a particular type of insurance (individual or group) and claim specialty (medical or dental, for example). While claims adjuster, investigator and examiner jobs are predicted to decrease by 1% from 2016-2026, medical claims examiners can progress in their careers by learning about different areas of specialization and pursuing ICA certification. In 2017, the BLS listed the median annual salary for claims examiners, adjusters and investigators as $64,900.

Alternate Career Options

Similar careers in this field include:

Appraiser or Assessor of Real Estate

Education requirements vary by state but usually include an associate's or bachelor's degree, licensing and certifications. These professionals estimate property values of land and buildings for sales, loans, taxes and insurance purposes. Faster-than-average job expansion of 14% was predicted by the BLS for 2016-2026. An annual median wage of $54,010 was reported by the BLS for appraisers and assessors of real estate in 2017.

Construction or Building Inspector

Qualifications for this career include a high school diploma, knowledge of construction trades, on-the-job training and self-study in building standards and codes. Many areas require certifications or licensing as well. Job responsibilities include ensuring compliance with building ordinances and regulations in new construction, remodels and repairs. The BLS projected a 10% increase in jobs from 2016-2026 for this field, which is faster than average. The annual median salary among construction and building inspectors was $59,090 in 2017.

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