Senior Claims Resolution Specialist

University of California - Los Angeles Health; Los Angeles (CA); Vor Ort; USD 66.000 - 130.000; Vollzeit

Zusammenfassung

University of California Health in Los Angeles seeks a Claims Adjustment Specialist to analyze and process medical claim adjustments, ensuring accurate payments and compliance with CMS and DMHC guidelines. You will work on escalated claims, apply benefit plans and contracts, and communicate outcomes to providers and members.

The role emphasizes accuracy, documentation, and collaboration with internal stakeholders to resolve disputes and improve claims processing efficiency in a dynamic

Qualifikationen

• Bachelor's degree or equivalent experience in a related field.
• Minimum three years of medical claims processing or claims adjustment experience.
• Applies knowledge of healthcare reimbursement and payment methodologies.
• Interprets benefit plans, provider contracts, and fee schedules.
• Applies CMS and DMHC regulatory requirements to claims processing.
• Communicates claim outcomes clearly in written documentation.
• Maintains production and quality standards.

Aufgaben

• Review and process claim adjustments including overpayments, underpayments, refunds, stale checks, and payment corrections.
• Analyze complex post-paid and escalated claims for accurate reimbursement and resolution.
• Apply benefit plans, fee schedules, provider contracts, and DOFR guidelines in adjudication.
• Research appeals, grievances, reconsiderations, and regulatory complaints to support timely resolution.
• Identify root causes of incorrect payments and recommend adjustments.
• Ensure CMS, DMHC, and internal policy compliance in processing.
• Review claim edits and coding updates to validate accuracy.
• Document and communicate claim outcomes to providers, members, and stakeholders.

Kenntnisse

Healthcare reimbursement knowledge

Claims processing

Regulatory compliance

Analytical thinking

Documentation and communication

Ausbildung

Bachelor's degree in healthcare administration, business, finance, or related field

Tools

Claims systems

Office software

Jobbeschreibung

University of California Health in Los Angeles seeks a Claims Adjustment Specialist to analyze and process medical claim adjustments, ensuring accurate payments and compliance with CMS and DMHC guidelines. You will work on escalated claims, apply benefit plans and contracts, and communicate outcomes to providers and members.

The role emphasizes accuracy, documentation, and collaboration with internal stakeholders to resolve disputes and improve claims processing efficiency in a dynamic