Make a difference in people’s lives every day. When you join UCLA Health, you’ll be working at an institution that provides leading-edge care to the people of L.A. and throughout the world. We provide our team members with the environment and support to do amazing work, because each and every one of them plays a vital role in our commitment to care.
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.
- 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
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VINCENT, Sr. CLS Specialist, Toxicology
MONICA
I've been blessed to touch so many lives through my serving. It's a privilege to uplift other employees with words of encouragement and a smile.
SOZIT
The first thing i noticed when i joined the team was how everyone is very welcoming and friendly with supportive management. I did not feel like an outsider.
EDGAR
Once I joined, I knew UCLA Health was THE place to be due to the growth potential and training offered
RENE
If you want to grow professionally, this is the right place for you.
ERA
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ELIZABETH
It’s so diverse and inclusive here. There’s always the opportunity to share your thoughts. It's a place where you feel you belong.
JERRY
Your career path at UCLA Health will enable you to follow a myriad of avenues and turns. It opens up a wide variety of opportunities.
ORLANDO
There’s a togetherness and higher level of commitment to teamwork at UCLA Health. We are several groups and teams that work together with a common goal which is to improve our patients experience.
KATHERINE
UCLA Health is a supportive, collaborative, and purposeful environment where leadership is invested in your growth and creating real opportunities. And knowing that what we do matters gives a real sense of purpose.
DR. ISLA GARRAWAY
UCLA has incredible resources and a team science approach. The ability to work with collaborative teams and access the amazing resources around campus is the best part about being at UCLA.
RADU
UCLA is very diverse in its personnel as well as its many research fields studied
JENNA
UCLA Health provides so many opportunities to exchange ideas, share moments and grow. I have learned a lot about team management and relationship building.
SHARON
I was looking for a job to further my career and continue to improve and learn as a therapist.
TARO
I have been blessed to be surrounded by supportive colleagues who aspire me to be the best version of myself.
Awards & recognition
