Claims Adjustments Specialist

Summary/Objective:

The adjustment specialist serves as a highly analytical claims professional responsible for ensuring financial accuracy, integrity, and compliance of medical claim payments and adjustments. This position leverages claims processing technology, data analysis, reimbursement methodologies, and mathematical calculations to identify, investigate, and resolve complex claim payment discrepancies, overpayments, pricing variances, and adjustment activity. The role is responsible for maintaining accuracy across MOE, WEX, and BCBS systems, processing specialized claim transactions, managing overpayment recovery efforts, securing appropriate pricing methodologies including NSA/QPA and blue card pricing, and ensuring all claim corrections align with plan documents, benefit provisions, regulatory requirements, and current processing guidelines. This position requires advanced problem-solving skills, attention to detail, and the ability to adapt to evolving system enhancements, business processes, and industry changes while maintaining productivity and quality standards.

Essential Functions:

• Maintain and monitor BCBS claim inventories, incentive reports, adjustment queues, and operational tracking reports to ensure timely processing and compliance with service standards.

• Process and adjust medical claims, including BlueCard, HST, WEX, transplant, NSA, out-of-network, single case agreement, and other specialized claim types in accordance with plan provisions, contractual requirements, and regulatory guidelines.

• Research, troubleshoot, and resolve claim processing issues, including rejected claims, system edits, mapping discrepancies, processing errors, and complex cross-system inquiries.

• Serve as a resource for claims examiners by identifying trends, recommending process improvements, and communicating training opportunities related to claim processing and adjustments.

• Manage refund, overpayment recovery, recoupment, payment correction, and stop-payment activities, including tracking, documentation, correspondence, and coordination with internal departments.

• Review provider late charges, corrected Medicare EOBs, special pricing requests, and high-dollar claims to ensure accurate payment determination and processing.

• Monitor backlog, error, reconciliation, and operational reports; analyze findings and recommend corrective actions to improve workflow efficiency and claim accuracy.

• Respond to inquiries and service requests within established service-level expectations.

• Maintain and update departmental procedures, process documentation, fraud provider listings, and other operational records to ensure compliance and consistency.

• Remain current on system enhancements, reimbursement methodologies, regulatory requirements, and process changes; participate in system testing and implementation activities as needed.

• Provide cross-functional support, process original claims during periods of increased volume, and perform other duties or special projects as assigned.

Education and Experience

• High School diploma or G.E.D. Certificate.
• Knowledge of medical terminology, CPT codes, and ICD-10 coding is required.
• Experience with dental claims processing
• Experience using Blue Cross/Blue Shield (BCBS) or subsidiary claims processing systems.
• Previous experience with claims adjustment processing.

Length of Experience:

• Minimum of 2 years of claims processing experience

Specialized skills/technical knowledge required:

• Strong mathematical, analytical, and problem-solving skills with the ability to accurately calculate claim payments, overpayments, recoveries, and reimbursement amount while identifying and resolving complex claim issues.
• Working knowledge of healthcare claims processing, medical coding, and reimbursement methodologies, including CPT, ICD-10, DRG, Medicare, COB, Critical Care, NSA, and QPA pricing.
• Ability to interpret plan documents, benefit provisions, contractual agreements, and regulatory requirements to make sound claims determinations.
• Proficiency with claims administration systems and related technologies, including ISSI or similar platforms, BCBS applications, and workflow management tools.
• Advanced Microsoft Excel skills for data analysis, reconciliation, reporting, and operational tracking.
• Ability to analyze system functionality, claim processing workflows, and operational data to identify trends, improve efficiencies, and support process enhancements.
• Strong organizational, time management, and multitasking skills with the ability to meet deadlines in a high-volume production environment.
• Excellent written, verbal, and interpersonal communication skills, with the ability to effectively collaborate across departments and communicate complex information clearly.
• Exceptional attention to detail, accuracy, and quality while working independently and as part of a team.
• Ability to professionally manage sensitive payment, recovery, and provider-related issues while maintaining confidentiality and customer service standards.