Health Insurance Claims Specialist

Job Summary

The Health Insurance Claims Specialist role will support attorneys by reviewing claim files, compiling factual summaries, identifying key documents and facilitating legal analysis regarding liability, potential defenses, exposure valuations, and settlement strategies.

Job Responsibilities

• Review and analyze health care claim files involved in payor/provider disputes, identifying patterns and administrative issues such as coding errors, denial reasons, and medical necessity claims.
• Evaluate merits and potential liability of claim batches to assess applicability to claims in dispute
• Review claim analysis and data from clients to validate findings, identify legal and factual issues, and support or challenge conclusions
• Maintain case summaries, claim trackers and databases ensuring accurate and timely communication with legal teams and clients.
• Synthesize information into actionable summaries to support legal analysis and trial strategy.

Knowledge, Skills, and Abilities

• Familiarity with health care insurance claims and strong working knowledge of payer-provider contracts, Medicare/Medicaid rules and regulations, and claims reimbursement frameworks.
• Experience reviewing and interpreting large volumes of healthcare claims data, EOBs, and denial codes.
• Strong written communication skills and ability to produce clear, concise and structured claim summaries.
• Excellent attention to detail, critical thinking and organizational skills.
• Proficiency with MS Suite and data driven analysis tools including document management systems, claims platforms, or litigation databases preferred.
• Ability to work collaboratively with attorneys and clients to provide support to litigation teams.

Education

The position requires a bachelor’s degree or equivalent combination of education and experience.

Experience

• The position requires a minimum of three (3) years of experience in health care claims analysis, insurance claims, payor-provider disputes, or litigation support with focus on managed care or regulatory compliance, or related field. 
• Prior experience at a law firm or insurance company handling health care litigation or audits.
• Familiarity with CMS manuals, coverage determinations, and medical necessity standards.
• Understanding of sampling and extrapolation methodologies.

Pay Range