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Job Description


Job Summary: This individual enters and adjudicates claims for all Health Plans products ensuring that all covered claims are paid in a timely basis. This individual also resolves questions regarding coverage of claims and benefits, functioning in the role of customer service representative for enrollees, other Health Plans Division Departments, providers and their office staff, and insurance companies. 


Job Duties/Responsibilities:

  • Analyzes and correctly processes claims in accordance with plan benefits and provider contracts in order to consistently meet or exceed the financial and statistical accuracy rates as established in the Claims Department Performance Standards.
  • Consistently meets or exceeds the claims adjudication quota as set forth in the Claims Department Performance Standards.
  • Responsible for processing claims within the timeframe set forth by the Claims Department Performance Standards.


  • Associates degree or equivalent experience. 
  • Minimum 2 years’ experience in health care claims processing, preferably in a managed care environment, including customer service experience. 
  • Minimum 1 year experience in advanced computer systems.
  • Knowledge of medical terminology necessary, CPT-4 procedure and ICD-9 (10) diagnostic coding knowledge.
  • Excellent verbal and written communication skills; organizational skills; ability to interpret and apply established policy and procedure.
  • Ability to plan, organize, and maintain priorities and schedules, as well as assure that deadlines are met. 
  • Ability to maintain confidentiality.
  • Ability to perform data entry with speed and accuracy.


The job skills required for CLAIMS EXAMINER include Customer Service, Written Communication, Claim Processing, Data entry, CPT, Health care etc. Having related job skills and expertise will give you an advantage when applying to be a CLAIMS EXAMINER. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by CLAIMS EXAMINER. Select any job title you are interested in and start to search job requirements.

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The following is the career advancement route for CLAIMS EXAMINER positions, which can be used as a reference in future career path planning. As a CLAIMS EXAMINER, it can be promoted into senior positions as a Disability Claims Examiner Sr that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary CLAIMS EXAMINER. You can explore the career advancement for a CLAIMS EXAMINER below and select your interested title to get hiring information.

How to Become a Claims Examiner

If you are interested in becoming a Claims Examiner, you need to understand the job requirements and the detailed related responsibilities. Of course, a good educational background and an applicable major will also help in job hunting. Below are some tips on how to become a Claims Examiner for your reference.

Step 1 Understand the job description and responsibilities of a Claims Examiner

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Step 2 Knowing the best tips for becoming a Claims Examiner can help you explore the needs of the position and prepare for the job-related knowledge well ahead of time.

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Step 3 View the best colleges and universities for Claims Examiner

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