Health Insurance Claims Specialist

Overview

This Health Insurance Claims Specialist role supports attorneys by reviewing health care claim files, compiling factual summaries, and facilitating legal analysis related to liability, potential defenses, exposure valuations, and settlement strategies.

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 the 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 to ensure accurate and timely communication with legal teams and clients.
• Synthesize information into actionable summaries to support legal analysis and trial strategy.

Requirements

• 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, with the ability to produce clear, concise, 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

• Bachelor’s degree or an equivalent combination of education and experience.

Experience

• Minimum of three (3) years of experience in health care claims analysis, insurance claims, payor-provider disputes, or litigation support with a focus on managed care or regulatory compliance, or a 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.

Compensation & Benefits

Pay range (by location):

• $81,000 - $120,000 — Boston, Chicago, Dallas, Denver, Los Angeles, Minneapolis, Orange County, Waltham, and Washington DC
• $88,000 - $140,000 — NY & SF
• $76,000 - $120,000 — Other US locations

Location

• Boston, Chicago, Dallas, Denver, Los Angeles, Minneapolis, Orange County, Waltham, Washington DC
• NY & SF
• Other US locations
• Remote