Medical Claims Examiner

Who You Are: You are a detail oriented Medical Claims Examiner professional with experience supporting medical claims, insurance claims, healthcare administration, billing, collections, case management, records management. You can accurately manage sensitive medical, financial, and legal information while working across multiple electronic systems. You are organized, dependable, and capable of following established procedures while meeting productivity, accuracy, quality, and timeliness requirements. You communicate professionally and understand the importance of safeguarding private and sensitive information.

How You Will Make An Impact: You will support medical claims and healthcare cost recovery activities for a federal healthcare customer. Your work will help identify responsible third parties, process claims, track payments, maintain accurate case files, and recover healthcare costs owed to the government. Your attention to detail and commitment to quality will help ensure claims are properly documented, processed, tracked, and resolved in accordance with government procedures.

Responsibilities: Monitor shared organizational email inboxes and physical mail for incoming claims, correspondence, and inquiries. Process new referrals and establish Medical Affirmative Claims and Third-Party Collection case files. Enter claims and case information into ACMP and other required government systems. Maintain accurate electronic case files, tracking logs, correspondence, and supporting documentation. Research and collect authorized patient, beneficiary, treatment, billing, insurance, eligibility, and case-related information. Access medical, administrative, eligibility, and financial systems to obtain records, treatment timelines, billing statements, patient demographics, and related information. Verify patient and claim information and identify missing, inaccurate, or inconsistent data. Gather and organize medical records, accident reports, insurance information, billing data, and supporting documents for review. Properly name, index, upload, and maintain documents in SharePoint and government case-management systems. Record Third-Party Collection denial codes and payer responses. Complete standardized appeal templates and assemble appeal packages for higher-level review. Research potentially liable parties, insurance carriers, civilian attorneys, and other relevant entities. Prepare notices of claim using government-approved templates. Draft standard demand letters, settlement memoranda, and other routine correspondence for review and signature by authorized government personnel. Prepare and mail claims forms and supporting documentation when electronic submission is unavailable. Respond professionally to routine inquiries from insurance carriers, attorneys' offices, healthcare organizations, government personnel, and other authorized parties. Provide approved, non-sensitive documentation in accordance with government direction. Update case status information within required timeframes. Track case milestones, correspondence, follow-up actions, payment activity, and statute-of-limitations deadlines. Perform data cleanup and first-level quality reviews of claims, reports, case files, and supporting documentation. Process cash collection vouchers and support the routing of recovered funds to the appropriate line of accounting. Verify payments, settlements, unpaid balances, and case status using authorized financial systems. Assist with collecting productivity, claims-processing, payment, and financial-recovery metrics for monthly reporting. Follow established standard operating procedures, quality control requirements, and supervisory direction. Perform other duties as assigned.

The Team: Lawelawe Training Services is an SBA Certified 8(a) Native Hawaiian Organization-Owned Small Disadvantaged Business specializing in services for federal government customers, including program management and business transformation, human capital and training, digital solutions, and medical staff support. Here's What You NeedOne or more years of experience in medical or insurance claims, healthcare administration, billing, collections, case management, records management, legal support, or a related field. Associate or bachelor's degree in healthcare administration, business administration, paralegal studies, finance, insurance, or a related field is preferred. Experience reviewing and processing medical records, billing statements, insurance documentation, claims correspondence, payment records, or similar documents. Familiarity with healthcare billing, third-party collections, insurance denials, appeals, payment verification, or healthcare cost-recovery activities. Experience supporting a federal healthcare program, Department of Defense organization, federal agency, or government contractor is preferred. Strong attention to detail and the ability to accurately manage multiple electronic case files, deadlines, correspondence, and financial information. Experience working under established productivity, accuracy, timeliness, and quality-control requirements. Familiarity with ACMP, ABACUS, DEERS, GFEBS, JLV, MHS GENESIS, PEPR, SharePoint, or comparable healthcare and claims-management systems. Experience safeguarding HIPAA-protected records, PII, PHI, CUI, or other sensitive government information. Professional written and verbal communication skills and proficiency with Microsoft Word, Excel, Outlook, Teams, and SharePoint. Ability to work independently, follow detailed procedures, and learn multiple government claims, medical-record, eligibility, and financial systems. Public Trust or ability to successfully complete a government background investigation Must be a US Citizen Work Environment This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Position Type/Expected Hours of WorkThis is a full-time hybrid position, contingent upon contract award, Government approval, and availability of contract funding. Typical days and hours of work are Monday through Friday, 6:00 a.m.–6:00 p.m. Central Time, and may require overtime occasionally. Evening and weekend hours as required by business need. Employees must reside within the local commuting area of San Antonio, Texas. Employees will work on-site according to a rotating schedule and may telework from an approved location on other scheduled workdays.