Claims Adjustment Specialist

UCLA Outpatient Clinics; Los Angeles (CA); Hybrid; USD 43,000 - 85,000; Full time

Job summary

The UCLA Outpatient Clinics seeks a Claims Adjustment Specialist to analyze and process medical claim adjustments, ensuring accurate payment determinations in line with CMS, DMHC, and health plan guidelines. You will support appeals, reconsiderations, and regulatory complaints, identifying root causes of incorrect payments and applying corrective actions to maintain high production and quality standards.

This position offers a competitive hourly salary range and opportunities to impact patient

Responsibilities

• Review and process electronic and paper claim adjustments, including overpayments and refunds.
• Analyze complex post-paid and escalated claims to ensure accurate reimbursement.
• Apply benefit plans, fee schedules, provider contracts, and DOFR guidelines during adjudication.
• Research appeals, grievances, reconsiderations, and regulatory complaints to support timely resolution.
• Identify root causes of incorrect payments and implement corrective adjustments.
• Ensure CMS, DMHC, and internal processing policies are followed.
• Review claim edits and coding updates to validate accuracy.
• Maintain documentation and communicate outcomes with providers, members, and internal stakeholders.

Job description

The Claims Adjustment Specialist analyzes and processes medical claim adjustments related to overpayments, underpayments, provider corrected claims, and reimbursement discrepancies. This role conducts detailed research on complex and escalated claims to ensure accurate payment determinations and compliance with CMS, DMHC, and health plan guidelines. The position supports claims resolution activities involving appeals, reconsiderations, complaints, and payment corrections while maintaining production and quality standards.

Key Responsibilities

• Review and process electronic and paper claim adjustments involving overpayments, underpayments, refunds, stale checks, and payment corrections.
• Analyze complex post-paid and escalated claims to determine accurate reimbursement and appropriate claim resolution.
• Apply benefit plans, fee schedules, provider contracts, and Division of Financial Responsibility (DOFR) guidelines during claims adjudication.
• Research appeals, grievances, reconsiderations, and regulatory complaints to support timely claim resolution.
• Identify root causes of incorrect payments and recommend or apply corrective adjustments.
• Ensure compliance with CMS, DMHC, and internal claims processing policies and procedures.
• Review claim edits, coding updates, and system outputs to validate accurate claims processing.
• Maintain accurate documentation and communicate claim outcomes with providers, members, and internal stakeholders as needed.

Note

This posted position is 2 of 4 positions available for hire. All applicants will apply through this requisition and if selected will be hired into one of the available positions.

Salary Range: $31.51 - $62.64/hour