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#92008 Claims Specialist-Managed Care

Filing Deadline: Tue 2/27/2018

UCSD Layoff from Career Appointment: Apply by 02/16/2018 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor. Eligible Disability Counseling and Consulting services (DCC) or Special Selection clients should contact their Vocational Rehabilitation Counselor for assistance.


The Claims Specialist is responsible for administering UCSD's delegated HMO contracts by processing complex medical claims for all lines of business in an efficient, cost effective and timely manner. Responsible for determining financial responsibility between group, health plans and contracted hospitals for accurate claim processing. Understands COB adjudication. Responsible for requesting and tracking overpayments and trends. Investigates and response to all appeals and tracks trends. Knowledge of health plan claims resolution reports.


  • High school diploma or equivalent.
  • Recent claim processing experience in a managed care/IPA environment.
  • Minimum five (5) years relevant claims experience.
  • Experience with Epic AP Claims claim processing system.
  • Excellent verbal and written communication skills.
  • Expert knowledge of current HMO claim processing protocols and regulatory guidelines.
  • Extensive knowledge of AWP (Average Wholesale Price) calculation.
  • Extensive knowledge of CPT, ICD, ASA and HCPCS coding as pertains to claim adjudication.
  • Proficiency with MS Word, MS Excel, MS Outlook, and Internet Explorer.


  • Four 4-year college degree.
  • Healthcare environment experience.
  • Knowledge of CMS Part B/Part D drug coverage guidelines.
  • Strong working knowledge of Medicare Diagnosis-Related Group (DRG) pricing, OPPS APC pricing, Ambulatory Surgery pricing, and RBRVS payment.


  • Must be able to work various hours and locations based on business needs.
  • Employment is subject to a criminal background check and pre-employment physical.
  • Must have 95% audit results.
  • Must have production average of 15 claims per hour.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, and several outpatient clinics. UC San Diego Medical Center in Hillcrest is a designated Level I Trauma Center and has the only Burn Center in the county. We invite you to join our dynamic team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

UC San Diego Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity or sexual orientation. For the complete University of California nondiscrimination and affirmative action policy see: http://www-hr.ucsd.edu/saa/nondiscr.html

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health Sys
Payroll Title:
UCSD Managed Care Network Mgmt
Salary Range
Commensurate with Experience
Greenwich Drive
Appointment Type:
Appointment Percent:
CX Contract
Total Openings:
Work Schedule:
Days, 8 hrs/day, Mon-Fri


As a federally-funded institution, UC San Diego Health maintains a marijuana and drug free campus. New employees are subject to drug screening.