Medical Claims Examiner
Career GuideKey Responsibilities
- Review medical claims for completeness, accuracy, and eligibility
- Verify coverage rules and benefit limits for each claim
- Check procedure and diagnosis codes for correctness
- Request and review supporting documentation such as medical records
- Approve, deny, or adjust claims based on policy and clinical guidelines
- Calculate member cost sharing such as copays, coinsurance, and deductibles
- Identify potential overpayments and underpayments and initiate corrections
- Document decisions clearly and maintain an audit-ready trail
- Respond to provider inquiries and support claim reconsiderations
- Escalate suspected fraud, waste, or abuse to the appropriate team
Top Skills for Success
Attention to Detail
Written Communication
Time Management
Customer Service
Policy Interpretation
Medical Terminology
Claims Adjudication
Coding Fundamentals
Regulatory Compliance
Fraud Awareness
Career Progression
Can Lead To
Senior Medical Claims Examiner
Claims Quality Analyst
Claims Team Lead
Utilization Review Specialist
Appeals Specialist
Provider Relations Specialist
Transition Opportunities
Claims Supervisor
Claims Manager
Compliance Analyst
Payment Integrity Analyst
Healthcare Operations Analyst
Medical Billing Manager
Common Skill Gaps
Often Missing Skills
Coding FundamentalsRegulatory ComplianceDocumentation QualityClaims Systems ProficiencyData FluencyAppeals Handling
Development SuggestionsBuild confidence by practicing code lookups and claim scenarios, learning the basics of Medicare and Medicaid rules, and strengthening written decision notes. Ask to shadow quality review or appeals work, and track personal accuracy and turnaround time to show measurable improvement.
Salary & Demand
Median Salary Range
Entry LevelUSD 38,000 to 50,000
Mid LevelUSD 50,000 to 65,000
Senior LevelUSD 65,000 to 85,000
Growth Trend
Steady demand. Hiring is supported by ongoing claims volume, Medicare and Medicaid complexity, and increased focus on payment accuracy and compliance.Companies Hiring
Major Employers
UnitedHealth GroupElevance HealthCVS HealthCignaHumanaKaiser PermanenteCenteneMolina HealthcareBlue Cross Blue Shield organizationsOptum
Industry Sectors
Health insurance carriersThird party administratorsManaged care organizationsGovernment health programsHospital systemsHealthcare billing services
Recommended Next Steps
1
Update your resume with measurable claim volume, accuracy rate, and turnaround time2
Learn the basics of ICD coding, CPT coding, and HCPCS coding3
Review common denial reasons and create a personal checklist to reduce repeats4
Request cross training in appeals, provider calls, or quality review5
Strengthen medical terminology and anatomy knowledge through a short course6
Practice writing clear claim decision notes that explain the reason and the next step7
Set a goal to improve one metric each month such as accuracy, productivity, or rework rate