Medical Claims Adjuster Job Description [Updated for 2025]

In the rapidly evolving field of healthcare, the role of medical claims adjusters is more critical than ever.

As the healthcare industry expands, so does the demand for skilled professionals who can effectively process, investigate, and manage medical claims.

But let’s delve a bit deeper: What’s truly expected from a medical claims adjuster?

Whether you are:

• A job seeker trying to comprehend the core responsibilities of this role,
• A hiring manager sketching out the perfect candidate,
• Or simply fascinated by the intricate world of medical claims adjusting,

You’re in the right place.

Today, we present a customizable medical claims adjuster job description template, tailored for effortless posting on job boards or career sites.

Let’s dive right into it.

Medical Claims Adjuster Duties and Responsibilities

Medical Claims Adjusters are responsible for reviewing, investigating, and managing insurance claims to determine the extent of the insuring company’s liability.

They are essential in the healthcare industry, ensuring the accurate processing and prompt payment of claims.

Their duties and responsibilities include:

• Reviewing and evaluating insurance claims for accuracy and completeness
• Investigating and managing insurance claims to determine the extent of the insurer’s liability
• Interacting with claimants, medical professionals, and insurance providers to gather necessary information
• Interpreting the policy coverage and determining if the claim is covered
• Calculating and validating claim amounts based on the terms of the policy
• Negotiating settlements with claimants, attorneys, or insurance agents
• Documenting all steps in the claim process, from initial evaluation to final settlement
• Identifying potential fraudulent claims and referring them for further investigation
• Keeping up-to-date with healthcare regulations and the latest medical procedures to accurately assess claims
• Maintaining professional and technical knowledge by attending educational workshops and reviewing professional publications

 

Medical Claims Adjuster Job Description Template

Job Brief

We are looking for a diligent Medical Claims Adjuster to investigate, evaluate, negotiate and resolve medical insurance claims.

The Medical Claims Adjuster’s responsibilities will include gathering and analyzing information to determine the extent of the insurance company’s liability, negotiating settlements with claimants, and ensuring that claims are settled correctly and efficiently.

Our ideal candidates are detail-oriented, possess excellent negotiation and communication skills, and have a good understanding of medical terminology and procedures.

Ultimately, the role of the Medical Claims Adjuster is to ensure the fair and prompt closing of medical claims according to company policies and procedures.

 

Responsibilities

• Analyze and process complex medical insurance claims
• Verify and update necessary information and record all data in relevant databases
• Communicate with claimants, medical professionals, and insurance agents
• Negotiate settlements with claimants and issue payments
• Identify suspicious claims and refer them for investigation
• Ensure compliance with state regulations and company policies
• Prepare reports on claim settlement activities
• Stay updated with changes in medical coding, billing practices and regulations

 

Qualifications

• Proven work experience as a Medical Claims Adjuster or similar role
• Knowledge of medical terminology and procedures
• Excellent negotiation and communication skills
• Proficiency in MS Office and data entry
• Good math and analytical skills
• Strong attention to detail and organizational skills
• Bachelor’s degree in Healthcare Administration, Business or related field

 

Benefits

• 401(k)
• Health insurance
• Dental insurance
• Retirement plan
• Paid time off
• Continuing education opportunities

 

Additional Information

• Job Title: Medical Claims Adjuster
• Work Environment: Office setting with options for remote work. Some travel may be required for investigations or consultations.
• Reporting Structure: Reports to the Claims Manager or Director of Claims.
• Salary: Salary is based upon candidate experience and qualifications, as well as market and business considerations.
• Pay Range: $50,000 minimum to $80,000 maximum
• Location: [City, State] (specify the location or indicate if remote)
• Employment Type: Full-time
• Equal Opportunity Statement: We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
• Application Instructions: Please submit your resume and a cover letter outlining your qualifications and experience to [email address or application portal].

 

What Does a Medical Claims Adjuster Do?

Medical Claims Adjusters typically work for insurance companies, healthcare institutions, or as independent contractors.

They are responsible for reviewing and assessing medical claims to determine the extent of the insurance company’s liability.

This involves analyzing medical reports and bills, interviewing medical experts, and sometimes even interacting with claimants to gather more information.

Their job is to ensure that the claim is valid and the expenses are reasonable and necessary.

They may also negotiate with healthcare providers about the cost of services and treatment provided.

Medical Claims Adjusters can also be responsible for determining the appropriate compensation for the claimant, based on their policy coverage.

In addition, they handle any disputes or appeals related to the claim, working closely with legal teams if necessary.

Their ultimate goal is to ensure that the claim process is fair and efficient, and that the insurance company pays out only what is rightly owed according to the policy terms.

 

Medical Claims Adjuster Qualifications and Skills

A proficient Medical Claims Adjuster should possess the skills and qualifications that are necessary for the role, including:

• Expertise in understanding, reviewing, and interpreting medical bills, medical records, and health insurance policies
• Strong analytical skills to examine complex medical claims and validate the accuracy and legitimacy of the claim
• Exceptional attention to detail to ensure that all data and information related to the claims are accurate and complete
• Excellent communication skills to interact with claimants, medical professionals, and insurance company representatives
• Interpersonal skills to empathetically handle clients who may be going through medical distress
• Proficiency in using medical billing software and other related computer applications
• Strong negotiation skills to settle claims in the most cost-effective manner
• Ability to handle multiple tasks simultaneously and make decisions under pressure
• Knowledge of medical terminology, procedures, and diagnosis codes to accurately assess claims
• Problem-solving skills to identify inconsistencies or discrepancies in claims and find appropriate solutions

 

Medical Claims Adjuster Experience Requirements

Entry-level Medical Claims Adjusters are typically required to have at least one to two years of experience, often achieved through internships or part-time roles in insurance or healthcare settings.

These professionals may have gained experience in roles such as medical billing and coding, claims processing, or healthcare administration.

Candidates with more than three years of experience often have developed a comprehensive understanding of medical terminologies, coding and billing procedures, and medical claims processing.

These professionals may have initially worked in roles such as Medical Claims Clerk or Claims Processing Specialist.

Those with over five years of experience are usually considered highly experienced in the field.

They may have a background of handling complex claims and disputes, with exposure to negotiating settlements.

They might also have some leadership or supervisory experience, being ready for managerial roles or team lead positions in the medical claims adjusting domain.

In addition, many employers prefer their Medical Claims Adjusters to have relevant professional certifications such as Certified Professional Coder (CPC) or Certified Medical Reimbursement Specialist (CMRS), which often require significant practical experience to achieve.

 

Medical Claims Adjuster Education and Training Requirements

Medical Claims Adjusters typically need a high school diploma or equivalent as the minimum educational requirement.

Some employers, however, prefer candidates with a bachelor’s degree in fields such as business or finance.

Adjusters must also understand medical terms and procedures, and knowledge of insurance laws and regulations is essential.

Therefore, a background in healthcare or insurance can be beneficial.

Many claims adjusters gain experience working in other roles in the insurance industry before moving into the adjuster role.

They also need to acquire on-the-job training where they learn about claim investigation and settlement negotiation techniques.

Most states require licensure for this position.

The requirements for licensure usually involve completing pre-licensure education and passing a state-administered exam.

Continuing education is important for medical claims adjusters as they need to stay updated with the changes in insurance laws and policies.

Therefore, many adjusters opt for professional certification programs offered by organizations like the American Institute For Chartered Property Casualty Underwriters.

These programs cover a range of topics, including insurance law, medicine, and fraudulent claim recognition.

Strong computer skills, especially knowledge of software used in claims processing, are also essential for this role.

Medical claims adjusters should also have excellent communication and negotiation skills to deal effectively with claimants and insurance companies.

 

Medical Claims Adjuster Salary Expectations

A Medical Claims Adjuster earns an average salary of $61,050 (USD) per year.

The actual income can fluctuate based on the individual’s years of experience, level of education, and the location of employment.

Furthermore, the specific sector of employment within the medical insurance industry can also influence the salary.

 

Medical Claims Adjuster Job Description FAQs

What skills does a Medical Claims Adjuster need?

Medical Claims Adjusters should have excellent analytical skills to evaluate and investigate insurance claims thoroughly.

They should have strong communication and negotiation skills as they often interact with claimants and medical professionals.

Attention to detail is essential, as they need to be able to identify inconsistencies in documents and medical reports.

Knowledge of medical terminology and procedures, as well as the legal aspects of health insurance, is also important.

 

Do Medical Claims Adjusters need a degree?

Most Medical Claims Adjusters have a bachelor’s degree in a relevant field, such as business or finance.

However, some employers may accept significant work experience in place of formal education.

Additionally, all Medical Claims Adjusters must be licensed in their state, which generally involves completing pre-licensing education and passing a state-administered exam.

 

What should you look for in a Medical Claims Adjuster resume?

Look for a combination of education and relevant work experience on a Medical Claims Adjuster resume.

As this role requires a strong understanding of medical terms and procedures, relevant experience in the healthcare field can be beneficial.

A valid state license for claims adjusting is mandatory.

Also, any certifications related to insurance or health care claims adjusting could be a plus.

 

What qualities make a good Medical Claims Adjuster?

A good Medical Claims Adjuster is detail-oriented and has strong analytical skills to review complex medical documents accurately.

They should be excellent communicators, able to explain insurance terms and decisions to claimants clearly.

They should also have good negotiation skills, as they often have to negotiate claim settlements.

Patience and empathy are crucial, as they often deal with claimants who may be dealing with medical issues and financial stress.

 

How challenging is it to become a Medical Claims Adjuster?

Becoming a Medical Claims Adjuster can be challenging, as it requires a combination of formal education, licensing, and on-the-job experience.

One must be knowledgeable about medical terminology, insurance law, and investigative techniques.

The role also demands a high level of analytical skills and attention to detail.

However, with the right education and experience, it can be a rewarding career in the insurance industry.

 

Conclusion

And there it is.

Today, we’ve unraveled the complexities of being a medical claims adjuster.

Surprised?

It’s not just about evaluating insurance claims.

It’s about shaping the landscape of healthcare, one claim at a time.

With our handy medical claims adjuster job description template and real-life examples, you’re equipped for the next step.

But why limit yourself?

Dig deeper with our job description generator. It’s your go-to tool for crafting pinpoint-accurate job listings or honing your resume to perfection.

Remember:

Every claim you adjust contributes to the broader healthcare system.

Let’s shape that future. Together.

How to Become a Medical Claims Adjuster (Complete Guide)

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