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Medical Claim Assessor Jobs (NOW HIRING)

The Whiteside Agency

Chief Medical Officer

Tampa, FL

$262K - $404K/yr

Lead the strategy and operations of Travelers Claim Medical initiatives focusing on how ... Stay connected to industry and relevant external bodies/associations to assess trends and ...

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Medical Claim Assessor information

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How much do medical claim assessor jobs pay per hour?

As of Aug 30, 2026, the average hourly pay for medical claim assessor in the United States is $16.83, according to ZipRecruiter salary data. Most workers in this role earn between $15.38 and $18.27 per hour, depending on experience, location, and employer.

What does a medical claim assessor do?

A Medical Claim Assessor is responsible for reviewing and evaluating health insurance claims to determine their validity and the extent of coverage. They analyze medical records, policy documents, and billing information to ensure claims are accurate and comply with policy guidelines. They may also communicate with healthcare providers, policyholders, and other stakeholders to gather necessary information. The assessor's goal is to ensure fair and timely settlement of claims while detecting any potential fraud or discrepancies.

What are the key skills and qualifications needed to thrive as a medical claim assessor?

To thrive as a Medical Claim Assessor, you need strong analytical skills, attention to detail, and knowledge of healthcare terminology, typically supported by a background in insurance, healthcare administration, or a related field. Familiarity with claims management software, ICD-10 coding systems, and regulatory guidelines is essential. Excellent communication, critical thinking, and organizational skills help assess claims efficiently and interact with clients or healthcare providers. These skills are vital to ensure accurate processing, minimize errors, and maintain compliance with industry standards.

What are some common challenges faced by medical claim assessors, and how can they be managed effectively?

Medical Claim Assessors often encounter challenges such as interpreting complex medical terminology, ensuring the accuracy of submitted documentation, and balancing efficiency with thoroughness. Managing these challenges typically involves ongoing training in medical coding, close collaboration with healthcare providers for clarification, and utilizing claims management software to streamline workflow. Effective communication and attention to detail are key to minimizing errors and ensuring fair claim outcomes.

What is the difference between Medical Claim Assessor vs Medical Claims Processor?

AspectMedical Claim AssessorMedical Claims Processor
Required credentialsRelevant certifications, such as insurance or healthcare qualificationsBasic administrative or insurance processing training
Work environmentOffice-based, healthcare or insurance companiesOffice or call center environments, insurance companies
Employer and industry usageInsurance providers, healthcare organizationsInsurance companies, third-party claims organizations
Common search intentUnderstanding roles, qualifications, and responsibilitiesProcessing claims, administrative tasks

The main difference is that Medical Claim Assessors evaluate and approve or deny claims based on policy and medical information, requiring specific healthcare or insurance credentials. Medical Claims Processors handle the administrative processing of claims, focusing on data entry and documentation. Both roles are essential in the insurance industry but differ in responsibilities and required qualifications.

How to be a medical claim assessor?

To become a medical claim assessor, typically one needs a background in healthcare, insurance, or related fields, along with knowledge of medical terminology and claims processing. Relevant certifications, such as a medical billing or insurance claims certification, can enhance job prospects. Strong analytical skills and attention to detail are essential for evaluating medical claims accurately.

How to become a medical claim assessor?

To become a medical claim assessor, candidates typically need a background in healthcare, insurance, or related fields, along with strong analytical and communication skills. Relevant certifications, such as a claims or insurance qualification, can enhance employability, and experience with medical records or claims processing is often preferred. Training is usually provided on the job, and a good understanding of medical terminology and insurance policies is essential.

Is claims processing a stressful job?

Medical claim assessors often find claims processing to be a demanding task due to strict deadlines, detailed documentation, and the need for accuracy. The job requires strong attention to detail and sometimes involves handling complex or disputed claims, which can contribute to stress levels. However, workload and stress can vary depending on the employer and individual experience.

What states have the most Medical Claim Assessor jobs?

States with the most job openings for Medical Claim Assessor jobs include:

Medical Claim Assessor jobs near you
Infographic showing various Medical Claim Assessor job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 77% Full Time, 15% Part Time, and 7% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution, with an average salary of $35,000 per year, or $16.8 per hour.

Medical Compliance Auditor

Texas Children's Hospital

Bellaire, TX

Full-time

Re-posted 10 days ago

Texas Children's Hospital rating

8.3

Company rating: 8.3 out of 10

Based on 177 frontline employees who took The Breakroom Quiz

86th of 1,064 rated hospitals

Job description

We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.

Think you've got what it takes?

Job Duties & Responsibilities 
   Assess the treatment plan, clinical information, and medical necessity of all requested services 
   Utilizes established criteria to appropriately review billed services within established timeframe required. 
   Consults with medical directors and clinical staff regarding patient's history and current care needs and whether services billed were appropriate. 
   Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action. 
   Telephonic follow-up with the provider's office to request additional information as needed. 
   Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit. 
   Evaluate benefit coverage and regulatory guidelines pertinent to decision making for each investigation. 
   Perform Clinical and Coding Review on Medical Claim Appeals. 
   Assess and process all education and recoupment letters after Special Investigative Committee review decision. 
   Facilitates provider communication and education. 
   Liaisons with internal staff members. 
   Perform Clinical Review and make recommendation on Audit Pass/Fail. 
   Ongoing assessment for quality indicators and concerns.


Skills & Requirements 
    Required Associate's Degree in Nursing  or
    Technical Diploma in Vocation Nursing
    Preferred Bachelor's Degree in Nursing
    Required LVN - Lic- Licensed Vocational Nurses Texas Board of Nursing or Nursing Licensure Compact or 
    RN-Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact 
    Preferred CPC-Cert-Cert Professional Coder Americal Academy of Professional Coders
     Required 3 years Clinical experience in the applicable field according to the license (LVN or RN) 
     4 years of Medical Auditing experience.
 

Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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