Complex Denials Consultant (Complex Claims)

Overview

This role is part of the Complex Claims team and focuses on healthcare provider claim disputes involving workers compensation (WC), motor vehicle accident (MVA), third party liability (TPL), and veterans’ affairs (VA). The Complex Denials Consultant represents healthcare providers by interpreting and applying state-specific statutes, advising on billing sequencing, and helping internal stakeholders develop strategies to recover on denied claims. Success in this role requires a foundational understanding of relevant regulations impacting payment, coverage, lien filing practices, and related topics.

Responsibilities

• Oversee and assist in pursuing reimbursement for denied WC, MVA, Other TPL, and VA claims.
• Draft complex appeals, correspondence, and other documents as appropriate.
• Understand and apply state-specific statutes related to WC claims.
• Oversee lien practices to ensure compliance with applicable state laws, Patient Protection Acts, and evolving case law.
• Assist with training recovery staff and provide feedback as requested by management.
• Coordinate with external counsel on strategy, pleadings, settlement posture, and cost-benefit analysis.
• Develop new legal and procedural arguments and tools for team use.
• Foster professional, collaborative relationships to facilitate favorable resolutions.

Requirements

• Law degree from an accredited college or university.
• Barred in one state or must be bar-eligible within 6 months of graduation.
• Legal experience with emphasis on one or more of the following:
  • Healthcare law
  • Insurance defense or plaintiff personal injury
  • Hospital or health system legal affairs
  • Complex reimbursement or lien litigation
• Strong working knowledge of:
  • MVA laws and insurance structures
  • Hospital lien statutes and enforcement
  • Regulatory compliance in healthcare reimbursement

Preferred Qualifications

Not specified.

Compensation & Benefits

• Base pay range: $90,000.00 - $112,762.49 per year.
• Individual pay is determined by role, level, location, job-related skills, experience, and relevant education or training.
• Bonus eligibility: This job is eligible to participate in the annual bonus plan at a target of 10.00%.
• A competitive benefits package is available.

Location

US-based position.