How to Become a Medical Claims Adjuster

Learn how to become a medical claims adjuster. Learn about the job description and duties and read the step-by-step process to start a career in medical claims.

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Do I Want to Be a Medical Claims Adjuster?

Medical claims adjusters, also commonly known as medical claims examiners, process medical claims, monitor medical bills for errors or uncovered items, negotiate bills when it is appropriate, and authorize the payment of medical claims. Other duties may include maintaining files, watching out for any fraudulent claims and conferring with patients and doctors to gather additional information when necessary.

Most medical claims adjusters work for health, life, or automobile insurance companies, although there are also opportunities for self-employment. Such professionals work in office settings, handling paperwork and using computers to complete tasks. This career is not physically demanding nor does it include risk of personal injury or illness. Long hours may be spent sitting, often looking at a computer screen.

Job Requirements

There is no standard educational requirement to become a medical claims adjuster. At minimum, individuals must have a high school diploma, and having a bachelor's degree or previous field experience can open doors for prospective candidates. The following table contains the core requirements for medical claims adjusters:

Common Requirements
Degree Level High school diploma or GED at minimum; employers may prefer to hire candidates with a bachelor's degree*
Degree Field Healthcare, medicine or other related field**
Experience Varies; at least three years of claims experience**
Licensure and Certification Licensure may be required in some states*; voluntary certifications available***
Key Skills Written and verbal communication, interpersonal and analytical skills*
Technical Skills Familiarity with medical procedures*; knowledge of medical terminology**

Sources: *U.S. Bureau of Labor Statistics, **Online job postings from employers (November 2012), ***Related professional organizations

Step 1: Get a Degree

Although it is not a strict requirement, having a bachelor's degree may offer increased job opportunities for aspiring medical claims adjusters. Having a strong background in medicine or healthcare is optimal. Programs in related areas, such as business or accounting, can give students the strong math, communication and negotiation skills needed to thrive in a business environment.

Step 2: Gain Experience

Having prior experience in medical insurance or claims processing is required or preferred by many employers. Individuals may gain necessary experience by working in medical office or in a related area, such as medical billing. Experience negotiating settlements, maintaining claims files and evaluating fraudulent claims can also be beneficial.

Step 3: Become Licensed

Some medical claims adjusters need licensure; specific laws vary from state-to-state. Some states allow claims adjusters working for large companies to work under the company's license, while other states mandate that all adjusters be licensed to practice. Licensure requirements usually include a minimum age, proof of completed education and passing a license examination. Other licensure requirements may include a criminal background check, submitting fingerprints for state records and paying a license fee.

Success Tips:

  • Keep learning. Taking continuing education courses and attending seminars is important for medical claims adjusters since laws change and are updated frequently. Continuing education allows medical claims adjusters to stay abreast of changing technologies, processes for handling claims and any policies regarding individual coverage.
  • Consider becoming certified. Voluntary certifications and designations are available through professional organizations, such as the Society of Registered Professional Adjusters (RPA) or the International Claim Association (ICA). Most certifications and designations require applicants to have at least five years of experience in the field. Other requirements include passing a test and completing some continuing education credits every year.
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