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

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

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.