Remote Claims Examiner III – Fraud & Compliance (RN/LPN)

Wis Phys Svc Ins Corp; Colorado; Remote; USD 43,000 - 55,000; Full time

Benefits offered by this job

Performance bonus

401(k) match

Health insurance

Dental insurance

Telehealth

Day-1 benefits

Job summary

Wisconsin Physicians Service (WPS) is seeking a Claims Examiner III LPN/RN to safeguard MVH program integrity by identifying, investigating, and preventing fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and ensure proper benefit administration.

The position supports audits and quality initiatives, collaborating with leadership and external partners to deliver well-documented recommendations.

Qualifications

• U.S. citizenship required due to DoD restrictions.
• RN or LPN licensure and current licensure status.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations, policies and procedures.
• Ability to analyze and document medical findings.

Responsibilities

• Analyze data from anti-fraud software and medical records to identify potential fraud or abuse.
• Develop and manage investigative cases; review claims histories and patterns.
• Perform pre- and post-payment reviews to determine medical necessity and compliance.
• Prepare data formats for physician and peer review; create audit summaries.
• Identify overutilization trends and irregular claim activity.
• Conduct audits and assess data from federal and internal sources.
• Work in a fast-paced, high-volume claims team.
• Draft professional correspondence to beneficiaries, providers and partners.

Skills

RN/LPN licensure

Clinical experience

MVH regulations knowledge

Medical data analysis

Education

Associate Degree in Nursing

Licensed Practical Nursing Program Certification

RN/LPN licensure (Current)

Tools

MS Excel

Job description

Wisconsin Physicians Service (WPS) is seeking a Claims Examiner III LPN/RN to safeguard MVH program integrity by identifying, investigating, and preventing fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and ensure proper benefit administration.

The position supports audits and quality initiatives, collaborating with leadership and external partners to deliver well-documented recommendations.