Fraud & Abuse Claims Auditor (RN/LPN) – Remote

WPS Health Solutions; Green Bay (WI); À distance; USD 22 000 - 31 000; Plein temps

Avantages offerts par ce poste

Remote and hybrid work options

Performance bonus

401(k) with 6% match

Competitive PTO

Health insurance

Dental insurance

Telehealth services

Résumé du poste

WPS Health Solutions in Madison, WI seeks a Claims Examiner III, Fraud and Abuse to identify and report fraud and abuse in MVH programs. You will analyze data, review medical records, and generate cases for investigators, while coordinating with MVH management and law enforcement as needed.

The role requires RN or LPN licensure with 3+ years of clinical practice, US citizenship, and the ability to work onsite near Madison with optional remote work as appropriate.

Qualifications

• Must live within vicinity of Madison, WI campus location, within 45 miles of WPS Headquarters.
• U.S. citizenship required due to DoD restrictions.
• Current RN or LPN licensure.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Responsabilités

• Identify fraudulent or abusive practices and report to MVH management.
• Review data from anti-fraud software to uncover potential fraud.
• Develop cases using medical records to identify aberrant patterns.
• Prepare professional correspondence to providers, beneficiaries, and authorities.
• Perform pre-payment and post-payment reviews to assess medical necessity.
• Participate in Quality Management System to maintain ISO certification.

Connaissances

Data analysis

Med records review

Report writing

Stakeholder comms

Regulatory compliance

Formation

Associate Degree in Nursing

LPN diploma/certificate

RN/LPN licensure

Description du poste

WPS Health Solutions in Madison, WI seeks a Claims Examiner III, Fraud and Abuse to identify and report fraud and abuse in MVH programs. You will analyze data, review medical records, and generate cases for investigators, while coordinating with MVH management and law enforcement as needed.

The role requires RN or LPN licensure with 3+ years of clinical practice, US citizenship, and the ability to work onsite near Madison with optional remote work as appropriate.