Claims Adjustment Specialist

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.