Claims Adjustment Specialist

Claims Adjustment Specialist

Company: University of California

Location: Los Angeles, California, USA

Job Type: Full-Time | Career Position

Work Schedule: Monday–Friday

Working Hours: 7:00 AM - 3:30 PM (PST)

Salary Range: $32.42 - $64.51 Per Hour

Job Number: 30761

Posted Date: September 21, 2026

Employment Duration: Indefinite

Open Positions: 4

Job Overview

The Claims Adjustment Specialist is responsible for reviewing, analyzing, and processing medical claim adjustments to ensure accurate reimbursement and timely resolution of payment discrepancies.

This role involves investigating complex and escalated claims, identifying overpayments and underpayments, processing corrected claims, and resolving reimbursement issues. The specialist will ensure compliance with applicable CMS, DMHC, and health plan regulations while supporting claims resolution activities, including appeals, reconsiderations, and payment corrections.

Key Responsibilities

• Review and process electronic and paper claim adjustments involving overpayments, underpayments, refunds, stale checks, and payment corrections.
• Investigate complex and escalated claims to determine appropriate reimbursement and resolution.
• Apply benefit plans, provider contracts, fee schedules, and Division of Financial Responsibility (DOFR) guidelines during claims processing.
• Research appeals, grievances, reconsiderations, and regulatory complaints to support timely resolution.
• Identify the root causes of payment discrepancies and implement appropriate corrective adjustments.
• Ensure compliance with CMS, DMHC, health plan requirements, and internal claims processing policies.
• Review claim edits, coding updates, and system-generated results to ensure accurate processing.
• Maintain detailed and accurate documentation of claims adjustments.
• Communicate claim outcomes and payment decisions to providers, members, and internal stakeholders.
• Meet departmental productivity, accuracy, and quality standards.

Required Qualifications

Education

• Bachelor's degree in Healthcare Administration, Business, Finance, or a related field.
• Equivalent relevant professional experience may be considered in place of a degree.

Experience

• Minimum 3 years of experience in medical claims processing or claims adjustment.

Technical and Professional Skills

• Strong understanding of healthcare reimbursement and payment methodologies.
• Ability to interpret benefit plans, provider contracts, and fee schedules.
• Experience analyzing complex post-payment claims and adjustment requests.
• Knowledge of CMS and DMHC regulatory requirements.
• Proficiency in claims processing systems and standard office applications.
• Strong analytical and problem-solving skills.
• Ability to identify payment discrepancies and support root cause analysis.
• Excellent written communication and documentation skills.
• Ability to prioritize multiple claims and meet required turnaround times.
• Commitment to maintaining productivity and quality standards.

Employment Details

Work Location: Los Angeles, California

Work Schedule: Monday–Friday

Working Hours: 7:00 AM - 3:30 PM

Employment Type: Full-Time

Position Status: Career

Duration: Indefinite

Compensation

Hourly Salary Range: $32.42 - $64.51

The final compensation will be determined based on relevant experience, qualifications, skills, and organizational requirements.

Additional Employment Requirements

• Final candidates must disclose any qualifying misconduct-related administrative or judicial decisions within the past seven years, as well as any appeals of substantiated misconduct findings involving previous employers.
• Current and former University of California employees may be subject to a personnel file review.

How to Apply

Interested candidates can apply through the organization's official careers website.

Job Number: 30761

Note: This recruitment covers multiple openings. Applicants will be considered for available Claims Adjustment Specialist positions through the same requisition.