Medical Claims Adjudicator Resume: 2 Samples, Job Description & Skills

Updated on: August 24, 2023

A medical claims adjudicator plays a vital role in the healthcare industry by reviewing and processing insurance claims to ensure accuracy, compliance with policies, and timely payment. As a highly detail-oriented professional, you’ll need a well-crafted resume that highlights your skills, experience, and qualifications.

In this webpage, we will provide you with two sample resumes to inspire and guide you in creating your own. We will also discuss the key responsibilities and job description of a medical claims adjudicator. Additionally, we will delve into the essential skills and qualifications that recruiters and hiring managers look for in candidates for this role.

Whether you’re an experienced medical claims adjudicator looking to update your resume or a newcomer to the field seeking to land your first job, this webpage is designed to be a valuable resource to help you stand out from the competition and secure your dream position in the medical claims industry.

Read on to gain insights, gather tips, and discover the best practices for crafting an impressive medical claims adjudicator resume. Let’s dive in!

Medical Claims Adjudicator Resume Sample 1

Sara Preece
32 Willow Street
Houston, TX 65552
(000) 989-7865 

Medical Claims Adjudicator

Highly skilled and detail-oriented Medical Claims Adjudicator with 8 years of experience in reviewing and processing medical claims for accuracy and compliance. Proficient in medical billing codes, insurance policies, and healthcare regulations. Strong analytical skills and ability to make quick and accurate decisions. Committed to providing exceptional customer service and maintaining a high level of accuracy in claims processing.


  • Excellent knowledge of medical billing codes (CPT, ICD-10, HCPCS) and insurance policies.
  • Strong understanding of healthcare regulations and compliance requirements (HIPAA, CMS).
  • Proficient in claims processing software and electronic health record systems.


Medical Claims Adjudicator
Kelly Services, Jamestown, ND
Jun 2018 – Present

  • Review and process medical insurance claims for accuracy, completeness, and compliance with policy guidelines.
  • Analyze medical records, billing codes, and supporting documentation to determine coverage and eligibility.
  • Collaborate with healthcare providers, policyholders, and medical billing specialists to resolve claim-related issues.
  • Ensure timely and accurate adjudication of claims within established guidelines and service level agreements.
  • Uphold confidentiality and adhere to privacy regulations in handling sensitive patient information.
  • Maintain accurate records of claims, correspondence, and other relevant documentation.
  • Provide exceptional customer service by addressing inquiries and concerns related to claims processing.

Medical Claims Processor
Care Centrix, Hartford, CT
May 2015 – Jun 2018

  • Verified and processed medical insurance claims in accordance with policy guidelines and industry standards.
  • Reviewed and validated medical billing codes, insurance coverage, and supporting documentation.
  • Collaborated with healthcare providers and policyholders to resolve claim discrepancies and ensure accuracy.
  • Maintained a high level of productivity and met or exceeded performance targets for claims processing.
  • Assisted in training new employees on claims processing procedures and company policies.

Bachelor of Science in Health Information Management
Anytown University – Hartford, CT


  • Detail-oriented
  • Strong analytical and problem-solving skills
  • Excellent communication and interpersonal skills
  • Ability to work independently and in a team-oriented environment
  • Exceptional organizational and time management skills

Excellent professional references are available

Medical Claims Adjudicator Resume Sample 2

Maria Young
53 Buckcreek Drive
Reno, NV 25896
(000) 444-1414
maria.young @ email . com


Seasoned Medical Claims Adjudicator with 5  years of successful experience in handling medical claims adjudication cases with a high score of success. Talented in delving deep into matters to bring out credible information, determining the eligibility of medical claims, adjudicating medical claims, and taking appropriate actions to resolve discrepancies.

• Eligibility Determination • Claims Verification
• Information Analysis • Regulatory Audits
• Alternatives Identification • Denial Handling
• Negotiation • Process Improvement
• Compliance • Claim Resubmission
• Scene Analysis


Medical Claims Adjudicator
Quality Health, Reno, NV
5/2020 – Present

  • Reviewed and processed medical insurance claims, ensuring accuracy and compliance with policy guidelines.
  • Utilized knowledge of medical billing codes, insurance policies, and healthcare regulations to determine claim eligibility.
  • Collaborated with healthcare providers and policyholders to resolve claim-related issues and answer inquiries.
  • Maintained detailed records of claims, correspondence, and other relevant documentation.
  • Worked efficiently to meet or exceed productivity and quality targets.

Insurance Claims Clerk
ABC Health, Reno, NV
1/2018 – 5/2020

  • Assisted in the processing of medical insurance claims, verifying accuracy and completeness.
  • Conducted research and investigations to resolve claim discrepancies and issues.
  • Provided support to the claims adjudication team by organizing and maintaining claim files.
  • Communicated with policyholders and healthcare providers regarding claim status and resolution.

High School Diploma
Reno High School, Reno, NV

Medical Claims Adjudicator Resume Page Image

Medical Claims Adjudicator Duties for Resume

As a medical claims adjudicator, you will play a crucial role in ensuring accurate and timely processing of medical claims. Your resume should highlight your skills and responsibilities in this role. Here are some duties and responsibilities statements to include:

Claims Processing: 
Efficiently review and analyze medical claims to determine their eligibility for reimbursement.

Documentation Review: 
Verify medical documentation and coding accuracy to ensure compliance with insurance policies and guidelines.

Claims Adjudication: 
Evaluate claims for accuracy, completeness, and adherence to established protocols.

Conduct thorough investigations to resolve claim discrepancies, including coordination with healthcare providers and policyholders.

Policy Knowledge: 
Stay updated with insurance policies and regulations to make informed decisions during the claims adjudication process.

Claims Resolution: 
Communicate with policyholders, healthcare providers, and other stakeholders to resolve claim-related inquiries or appeals.

Data Management: 
Accurately enter and maintain claim information in the database, ensuring confidentiality and data integrity.

Quality Assurance: 
Monitor and assess claim adjudication processes to identify areas for improvement and ensure accuracy and compliance.

Team Collaboration: 
Collaborate with cross-functional teams, including customer service, billing, and coding, to facilitate efficient claims processing.

Customer Service: 
Provide exceptional customer service by addressing policyholders’ concerns and questions related to claim adjudication.

Remember to tailor these statements to your specific experience and skills to create a compelling resume.

Medical Claims Adjudicator Skills for Resume

When highlighting hard skills on your resume as a medical claims adjudicator, it’s important to showcase your technical abilities and knowledge that directly relate to the role. Here are some essential hard skills to consider including:

1. Medical Terminology:
Proficient knowledge of medical terminology and coding systems such as ICD-10 and CPT codes.

2. Claims Processing Software:
Experience with using claims processing software, such as Epic, Medisoft, or other industry-specific platforms.

3. Data Analysis:
Ability to analyze data and make accurate decisions based on claim information and documentation.

4. Adjudication Guidelines:
Familiarity with insurance policies, guidelines, and industry regulations to make informed decisions during claims adjudication.

5. CPT and HCPCS Codes:
Understanding of Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes for accurate claim evaluation.

6. Medical Documentation Review:
Expertise in reviewing medical records, charts, and other documentation to determine claim validity and accuracy.

7. Insurance Knowledge:
Solid understanding of insurance policies, coverage limits, and claim submission processes.

8. Legal and Compliance:
Knowledge of healthcare laws, regulations, and compliance related to claims processing and adjudication.

9. Computer Skills:
Proficiency in using computer software and tools for data entry, document management, and communication.

10. Analytical Thinking:
Strong analytical and problem-solving skills to identify claim discrepancies and resolve complex issues.

By showcasing these hard skills on your resume, you can demonstrate your technical capabilities and suitability for the role of a medical claims adjudicator.

Final Thought

This webpage serves as a comprehensive resource for creating an impressive medical claims adjudicator resume. By capturing the key responsibilities, necessary skills, and offering two sample resumes, we provide valuable guidance for crafting a standout application. With these tools in hand, you’ll be well-equipped to showcase your expertise and land your dream job in the medical claims industry. Good luck on your resume journey!

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