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

WPS Health Solutions; Madison (WI); Sur place; USD 26 000 - 36 000; Plein temps

Résumé du poste

WPS Health Solutions seeks a Claims Examiner III, Fraud and Abuse, to identify and report fraudulent or abusive MVH practices. Must live within 45 miles of the Madison campus; U.S. citizenship required.

Onsite training possible; remote work currently available with some onsite requirements. Responsibilities include data reviews, case development, and coordinating with law enforcement. Qualified candidates have 3+ years clinical practice, RN or LPN licensure, and the ability to apply MVH

Qualifications

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

Responsabilités

• Generate reports and review data from anti-fraud software to uncover potential fraud or abuse.
• Develop cases, review statistical data and medical records to identify aberrant patterns.
• Compose letters to educate providers/beneficiaries, obtain information, and refer cases to law enforcement.
• Perform pre-payment and post-payment review of claims and medical records to determine medical necessity.
• Provide RN oversight on LPN decisions as required by MVH program regulations.
• Participate in Quality Management System to maintain MVH ISO certification.

Connaissances

Data analysis

Auditing

Medical documentation

Report writing

Formation

RN/LPN licensure

Nursing degree/diploma

Description du poste

WPS Health Solutions seeks a Claims Examiner III, Fraud and Abuse, to identify and report fraudulent or abusive MVH practices. Must live within 45 miles of the Madison campus; U.S. citizenship required.

Onsite training possible; remote work currently available with some onsite requirements. Responsibilities include data reviews, case development, and coordinating with law enforcement. Qualified candidates have 3+ years clinical practice, RN or LPN licensure, and the ability to apply MVH