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 Qualifications All items below are required : Bachelor’s degree in healthcare administration, business, finance, or a related field, or equivalent experience Minimum three years or more of experience in medical claims processing or claims adjustment Applies knowledge of healthcare reimbursement and payment methodologies Interprets benefit plans, provider contracts, and fee schedules Analyzes complex post paid claims and adjustment requests Applies CMS and DMHC regulatory requirements to claims processing Utilizes claims systems and standard office applications effectively Communicates claim outcomes clearly in written documentation Prioritizes and manages multiple claims within required turnaround times Applies analytical judgment to identify payment discrepancies Supports root cause analysis related to claims processing issues Maintains production and quality standards in accordance with department policy