Medical Claims Processor / Specialist

Medical Claims Processor / Specialists process, review, and adjudicate healthcare insurance claims, working either on the payer side (insurance companies) or the provider side (medical practices and billing departments). The work involves checking claims for accuracy and eligibility, applying coding and coverage rules, and resolving discrepancies between what was billed and what's owed. Our medical claims processor job description covers the full scope of the role.

On the payer side, this often means reviewing claims against plan benefits and medical necessity guidelines. On the provider side, it leans more toward claims follow-up, appeals, and working denials until they're resolved or written off appropriately. Either way, familiarity with EOBs, CPT and ICD-10 codes, and payer-specific claims requirements is expected.

Health insurance companies, third-party administrators, and healthcare provider billing departments are the main employers for this role. Some positions require specific experience with Medicare or Medicaid claims processing, since government payer rules differ meaningfully from commercial insurance.

Pay depends on the complexity of the claims being handled and whether the role includes appeals or audit responsibilities, with claims adjuster and senior claims analyst roles reaching higher. Our medical claims processor salary guide breaks down current ranges.