A medical claims processor works on the payer side of a health claim: at the payer that receives the claim a provider submits — a health plan or Medicare contractor, for example.
Processors check incoming claims for complete and valid information, apply the plan's payment rules, and move each claim to a decision — pay it, deny it, or return it to the provider for correction.
This guide covers the work, the employers, entry requirements, pay, and the path up to examiner.
What claims processors do
A medical claims processor works on the payer side of a health claim.
The work goes by several titles — medical claims specialist and healthcare claims processor among them.
Once a provider submits a claim, someone at the payer that receives it has to check it and record the plan's decision — that is the processor's job.
Claims reach the payer in standard electronic formats.
CMS defines an institutional claim as one submitted on the ASC X12 837 institutional transaction or paper Form CMS-1450, and a professional claim as one on the ASC X12 837 professional transaction or the CMS-1500 paper form.
Both definitions cover an electronic transaction and a paper form.
HIPAA's adopted standard for dental, professional, and institutional health care claims is the ASC X12 837, version 005010, under 45 CFR 162.1102.
Processing starts by separating claims that can be decided from claims that cannot.
CMS says a Medicare claim returned as unprocessable for incomplete or invalid information is not considered a claim, is not denied, and has no appeal rights — it must be corrected and resubmitted.
That is the practical difference between a rejection and a denial, and it shapes what a processor does with each problem claim.
The decisions sit inside payer deadlines.
Under CMS's Medicare Claims Processing Manual (Publication 100-04, ch. 1, §80.2.1.1), clean Medicare claims received on or after October 1, 1993 must be paid or denied within 30 days, with interest owed on clean claims not paid within that ceiling.
Payment has a floor as well as a ceiling: Medicare contractors may not pay a clean claim before 13 days after receipt for electronic claims, or before 26 days for paper claims (Publication 100-04, ch. 1, §80.2.1.2).
Medicaid runs on its own federal timing rule.
Under 42 CFR 447.45(d), state Medicaid agencies must pay 90% of clean claims from practitioners within 30 days of receipt and 99% within 90 days.
When a claim is decided, the payer's output also runs on a HIPAA standard.
The ASC X12 835 (005010X221), adopted under 45 CFR 162.1602 for health care payment and remittance advice, is the electronic remittance advice (ERA) that carries the payer's payment and remittance information back to the provider's side.
These rules are payer-specific: the Medicare manual binds Medicare contractors, the CFR section governs state Medicaid agencies, and each plan carries its own terms.
A processor learns the rules of the plans they process for and confirms the details with each payer.
Payer rules are payer-specific, and they change
Who employs medical claims processors
The occupation BLS uses to count this work is not health-specific.
BLS defines insurance claims and policy processing clerks (SOC 43-9041) mainly around processing insurance policy applications, changes, and cancellations, which makes the code only a loose proxy for health claims work.
In BLS Employment Projections industry data for 2025, 81.3% of insurance claims and policy processing clerk jobs — 194,400 — were in finance and insurance, which shows how much of the occupation is other lines of insurance.
Direct health and medical insurance carriers employed 27,500 of these clerks (11.5%), and healthcare and social assistance employed 12,800 (5.4%).
For health claims work specifically, the verified federal numbers cover health plans and insurance carriers (27,500 clerks, above) and the Medicare contractors below.
Payer-side claims work also exists outside carriers: a third-party administrator (TPA) is a company that processes claims on another organization's behalf.
Our research found no federal employment figures for TPAs or other non-carrier claims shops, so treat each posting's employer description as the source of truth for who the job processes claims for.
Medicare claims are processed by contractors.
CMS lists 12 A/B Medicare Administrative Contractor (MAC) jurisdictions, four of which also process home health and hospice claims, plus four DME MAC jurisdictions.
One consequence of the all-lines occupation: a posting titled simply claims processor may belong to another line of insurance rather than health care.
The employer's description tells you which world a job sits in, so read it before you apply.
Skills and entry requirements
BLS's entry picture is straightforward: financial clerks — the BLS group that includes insurance claims and policy processing clerks, the closest available occupation for this work — typically need a high school diploma or equivalent, and they typically learn their duties through on-the-job training.
BLS lists communication skills, math skills, and organizational skills as the important qualities for financial clerks.
In claims processing those translate into reading claim data accurately, working a claim against the plan's payment rules, and keeping track of where every claim in a queue stands.
The job knowledge is payer-specific: the 837 institutional and professional claim formats, the difference between a returned claim and a denied one, and the payment rules of the plans being processed, from Medicare's 30-day clean-claim ceiling down to a single plan's terms.
Processors also work with members' protected health information.
HIPAA's minimum necessary standard (45 CFR 164.502(b)) requires covered entities and business associates to make reasonable efforts to limit protected health information to the minimum necessary for the intended purpose when using, disclosing, or requesting it.
Pay overview
The BLS occupation data this site uses has no line called medical claims processor.
The closest available group is insurance claims and policy processing clerks (SOC 43-9041), an all-lines insurance occupation that BLS defines mainly around policy application work.
In May 2025, BLS reported a median annual wage of $49,230 for the occupation, and its Employment Projections show employment falling 2%, from 239,100 jobs in 2025 to 234,700 in 2035.
Separate from the projection counts, May 2025 OEWS industry data shows a median of $50,800 at insurance carriers (73,830 employed) versus $45,900 in offices of physicians (5,160 employed).
Read all of these as the closest available BLS group, not as a medical claims processor salary survey.
The claims processor salary page has the full national, state, and metro tables from the same BLS release.
The path to examiner and analyst roles
On the payer side, the review roles sit a level above processing.
BLS describes claims examiners at health insurance companies as the workers who review health-related claims to see whether costs are reasonable given the diagnosis, then authorize payment, deny the claim, or refer it to an investigator.
That review-and-decide work is the direction payer-side processors look toward as they add responsibility: reasonable-cost review, payment decisions, and investigator referrals.
BLS reports a May 2025 median annual wage of $78,000 for claims adjusters, examiners, and investigators across all insurance lines, and $59,800 for those at direct health and medical insurance carriers.
Both figures sit above the processing occupation's $49,230 median, though BLS counts the two as separate occupations, so the comparison is between two proxies rather than two rungs of one measured ladder.
BLS projects the adjuster-examiner occupation to decline 6% from 2025 to 2035.
Titles differ — claims processor, claims examiner, and medical claims analyst are all in use — so compare the listed duties rather than the title alone when you judge any one job.
One thing to check before moving into examiner work is licensing.
BLS says licensing requirements for claims adjusters, appraisers, examiners, and investigators vary by state, and that an adjuster employed by an insurance company can work under the company license instead of their own, depending on the state.
Check with your state's insurance department for the current rule before you apply.
Find claims processor jobs
Search titles include medical claims processor, claims processor, insurance claims processor, healthcare claims processor, and medical claims specialist — and a plain claims processor posting may belong to another insurance line.
The employer's name tells you which side of the claim the job sits on: a health plan or Medicare contractor means payer-side processing, while a practice or billing company means provider-side billing work.
Browse the current medical claims processor jobs on MedicalBillingHires to see what is live today.
Hiring claims staff? Post a job on MedicalBillingHires to put your opening in front of billers, coders, and revenue-cycle staff.
Career information, not coding, billing-compliance, legal, or tax advice. Payer processing rules differ and change: confirm Medicare rules with CMS or the MAC for your jurisdiction, Medicaid rules with the state Medicaid agency, and licensing questions with your state's insurance department.