Healthcare Claims Review Attorney

About the Role

Capitol Bridge Puerto Rico is seeking an experienced attorney to support healthcare claim dispute resolution for the Florida CDR and multi-state IRO programs. The Healthcare Claims Review Attorney provides legal and regulatory analysis on complex disputes, supports development of defensible determination documentation, advises reviewers on legal or procedural questions, and helps ensure review activities remain aligned with applicable program requirements. The attorney works closely with RN reviewers, coding specialists, credentialed clinicians, Quality, and program leadership without replacing independent clinical judgment.

Salary Range: $70k-$80k

Key Responsibilities

• Review complex or escalated healthcare claim disputes for legal, regulatory, contractual, or procedural issues within program scope.
• Provide legal analysis and guidance to RN reviewers, coding specialists, physicians, and program leadership while preserving the independence of clinical determinations.
• Review applicable statutes, administrative rules, program guidance, contracts, and other governing authorities relevant to assigned disputes.
• Identify legal or procedural deficiencies, jurisdictional questions, documentation issues, or other risks that may affect dispute resolution.
• Review and support drafting of determination letters and other formal case communications for clarity, consistency, and defensibility.
• Assist with interpretation and implementation of regulatory, policy, and client-directed changes affecting review operations.
• Partner with Quality and Training to translate legal or regulatory changes into reviewer guidance, templates, and operational controls.
• Support escalations, audit responses, corrective actions, and complex-case discussions as requested by program leadership.
• Maintain clear documentation of legal analysis and recommendations in accordance with program requirements.
• Complete assigned work within required timelines and maintain confidentiality, privacy, and professional standards.

Required Qualifications

• Juris Doctor (J.D.) from an accredited law school.
• Active and unrestricted license to practice law in at least one U.S. jurisdiction, with eligibility to perform the duties assigned to this role.
• Experience interpreting statutes, regulations, contracts, administrative requirements, or other legal authorities.
• Strong legal research, analytical writing, and communication skills.
• Ability to work collaboratively with clinical, coding, quality, operational, and executive stakeholders.

Preferred Qualifications

• Healthcare law, health insurance, managed care, claims, reimbursement, administrative law, regulatory compliance, or healthcare dispute-resolution experience.
• Experience with state or federal healthcare programs, health plans, providers, or independent review organizations.
• Experience reviewing medical or claims-related disputes and translating regulatory requirements into operational guidance.
• Bilingual English/Spanish communication skills.

What Success Looks Like

The team receives timely, practical legal guidance that strengthens defensibility without slowing case flow or blurring clinical decision-making. Regulatory changes are translated into clear operational direction, and complex disputes are escalated and documented consistently.

Required Screenings

Employment is contingent upon successful completion of applicable background screening requirements.

Reasonable Accommodation

Reasonable accommodation may be made to enable qualified individuals with disabilities to perform the essential functions of this position. Additional duties may be assigned based on program needs.

Equal Employment Opportunity

Capitol Bridge Puerto Rico is an Equal Opportunity Employer. Employment decisions are based on business needs, job requirements, and individual qualifications, without regard to any status protected by applicable law.