Claims Examiner III - LPN

WPS Health Solutions; Madison (WI); Remote; USD 29,000 - 34,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus and merit increases

401(k) with a 100% match for the first

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the integrity of the Military Veteran Health program. You will analyze data, investigate potential fraud, and determine medical necessity while ensuring proper benefits administration.

The role involves cross-functional collaboration, auditing activities, and producing well-supported recommendations in a fast-paced, high-volume claims team. Remote work options may be available in approved states.

Qualifications

• U.S. citizenship is required due to DoD restrictions.
• Licensed RN or LPN with current licensure.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.

Responsibilities

• Analyze data from anti-fraud software, statistical reports, and medical records to identify potential fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases, reviewing claims histories and patterns that exceed norms; research allegations within MVH.
• Perform pre-payment and post-payment reviews of claims and medical records to assess medical necessity and MVH compliance.
• Compile data in formats suitable for Physician and PEER Review; create spreadsheets and audit summaries to support findings.
• Use medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct audits and assess data from federal/internal sources to strengthen program controls.
• Initiate professional correspondence with beneficiaries, providers, contractors, and external partners as needed.

Skills

Data analysis

Attention to detail

Written communication

Education

RN or LPN licensure

Tools

MS Excel

Job description

U.S. citizenship is required for this position due to Department of Defense restrictions.

Our Claims Examiner III LPN protects the integrity of the Military Veteran Health (MVH) program by identifying, investigating, and preventing potential fraud, waste, and abuse. They blend clinical expertise with data analysis to evaluate medical necessity, detect unusual utilization patterns, and ensure benefits are administered appropriately. This Claims Examiner collaborates with internal leadership and external oversight partners through clear communication, thorough case development, and well-supported recommendations. Contributing to audit activities and quality initiatives, this role helps maintain compliance and strengthens trust in the program.

Additional Information

• Pay rate: At least $21.78/hour
• Based on individual experience and county SCA rates.
• Training Location/Schedule: Monday-Friday 8am~4pm
• Scheduled Shift: Flexible schedule once trained, 8-hours continual shift between 7:00am CT ~ 5:00pm CT

Work Location

We are open to remote work in the following approved states:

• Colorado
• Florida
• Georgia
• Illinois
• Indiana
• Iowa
• Michigan
• Minnesota
• Missouri
• Nebraska
• New Jersey
• North Carolina
• Ohio
• South Carolina
• Texas
• Virginia
• Wisconsin

How do I know this opportunity is right for me? If you can:

• Analyze data from anti-fraud software, statistical reports, and medical records to identify potential fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases, including reviewing claims histories, evaluating patterns that exceed norms, and researching allegations of fraud and abuse within the MVH program.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity, appropriateness of care, and compliance with MVH policy.
• Compile and prepare data in formats suitable for Physician and PEER Review and create spreadsheets and audit summaries to support findings.
• Utilize medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess the significance of data from federal and internal sources to strengthen program controls.
• Ability to work in a fast past, high volume claims processing team.
• Initiate and compose professional correspondence with beneficiaries, providers, contractors, and external partners to obtain information, educate stakeholders, and refer cases to TMA or law enforcement when necessary.

Minimum Qualifications

• U.S. citizenship is required for this position due to Department of Defense restrictions.
• Licensed Registered Nurse (RN): Associate Degree in Nursing or equivalent diploma from accredited Nursing Program OR Licensed Practical Nurse (LPN): Accredited Practical Nursing Program Certification
• Current RN or LPN licensure.
• 3 or more years clinical practice experience.
• Ability to learn and apply governing MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Preferred Qualifications

• Strong experience using MS Excel.
• Bachelor of Science Degree in Nursing (RN).
• 5 or more years clinical practice experience with 2 or more years in an acute care setting.
• Fluent in a foreign language.
• Fraud prevention or medical auditing background.

Core Qualities for Success

• Ability to interpret medical records, claims data, and utilization patterns.
• Excellent written communication and professional correspondence skills.
• Attention to detail and comfort working with large datasets.
• Commitment to supporting program integrity and reducing fraud, waste, and abuse.

Remote Work Requirements

• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
• Please review Remote Worker FAQs for additional information.

Benefits

• Remote work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS' culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce-both current and future-to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.

This position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to all applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. DoD contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.