Lead Medical Claims Examiner

Who We Are

Lawelawe is a Native Hawaiian Owned Small Disadvantaged Business (NHO SDB) that specializes in providing a range of services to federal government clients, including program management, digital solutions, human capital and training, and medical staffing. Lawelawe leverages our NHO status to secure federal contracts that not only drive business success but also support our overall mission to uplift economically disadvantaged Native Hawaiian families and preserve the Native Hawaiian heritage.

An experienced, detail-oriented claims professional who can manage sensitive medical, financial, and legal information while helping a team deliver accurate and timely results. You are organized, dependable, comfortable working in multiple electronic systems, and able to guide coworkers, coordinate priorities, and identify issues requiring management attention. You communicate professionally and understand the importance of protecting private and sensitive information.

You will support medical claims and healthcare cost recovery activities for a federal healthcare customer. In addition to performing claims-examination duties, you will assist the Program Manager with workload distribution, daily workflow coordination, quality checks, and the scheduling of shared workstation usage. Your contributions will help the team maintain balanced workloads, meet deadlines, and recover healthcare costs owed to the Government.

• 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 Affi­ngative 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…