Lead Medical Claims Examiner

Lawelawe Training Services Inc • San Antonio, TX

10d • Hybrid

About The Position

Lawelawe is seeking an experienced, detail-oriented Lead Medical Claims Examiner to manage sensitive medical, financial, and legal information. This role involves supporting medical claims and healthcare cost recovery activities for a federal healthcare customer. The Lead Medical Claims Examiner will assist the Program Manager with workload distribution, daily workflow coordination, quality checks, and scheduling. This position is crucial for helping the team maintain balanced workloads, meet deadlines, and recover healthcare costs owed to the Government.

Requirements

• Three years of experience in medical claims, insurance claims, healthcare administration, billing, collections, case management, legal support, or a closely related field.
• At least one year of experience serving as a team lead, supervisor, senior specialist, or work coordinator, including assigning or coordinating work, monitoring progress, or mentoring coworkers. This experience may be included within the three years of relevant experience.
• Demonstrated ability to balance workloads, track deadlines, and coordinate competing priorities across a team.
• Ability to coordinate shared workspace usage and hybrid-work schedules under the direction of the Program Manager.
• Ability to provide clear procedural guidance, review work for accuracy, and professionally identify issues requiring management attention.
• 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.
• 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

Nice To Haves

• Associate or bachelor’s degree in healthcare administration, business administration, paralegal studies, finance, insurance, or a related field is preferred.
• Experience supporting a federal healthcare program, Department of Defense organization, federal agency, or government contractor is preferred.

Responsibilities

• Assist the Program Manager with distributing and balancing claims workloads based on case complexity, employee capacity, priorities, and deadlines.
• Monitor case progress, identify backlogs or workload imbalances, and recommend adjustments to the Program Manager.
• Coordinate shared workstation usage and the rotating on-site schedule under the Program Manager’s direction, communicating approved assignments and schedule changes to team members.
• Identify workstation scheduling conflicts, coverage gaps, and workspace constraints and elevate them to the Program Manager.
• Provide procedural guidance, peer training, and mentoring to Claims Examiners, including assistance with onboarding new team members.
• Maintain an assigned claims workload while performing lead-coordination 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.

Benefits

• A competitive compensation package
• Comprehensive health and wellness benefits, including medical, dental, and vision plans
• Access to company-provided retirement savings options with matching contributions
• Opportunities for professional growth and continued learning
• Additional perks such as discounts on various services and products

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree