Senior Fraud & Abuse Claims Examiner - RN/LPN (Remote)

WPS Health Solutions; Monona (WI); On-site; USD 22,000 - 31,000; Full time

Benefits offered by this job

Remote work option

Hybrid work options available

Health insurance (Day 1)

Job summary

WPS Health Solutions seeks a Claims Examiner III, Fraud and Abuse role to identify and report fraudulent or abusive MVH practices. Candidates will review data, develop cases, and coordinate with law enforcement when needed, while ensuring medical necessity aligns with MVH policies.

Position requires RN/LPN licensure with 3+ years clinical practice, DoD clearance eligibility, and ability to work from Madison, WI within 45 miles of the campus; remote work is possible with onsite training as needed.

Qualifications

• Must live within vicinity of Madison, WI campus location (within 45 miles).
• U.S. citizenship is required for this position due to DoD restrictions.
• Licensed RN (any equivalent) or Licensed Practical Nurse licensure required.
• Current RN or LPN licensure and 3+ years clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures; analyze and document medical findings.

Responsibilities

• Identify, develop, and report fraudulent or abusive practices in MVH.
• Review data from anti-fraud software and medical records to identify aberrant patterns.
• Prepare cases and communicate findings to physicians, peers, and law enforcement when needed.
• Conduct pre-payment and post-payment review of claims for medical necessity and MVH policy adherence.
• Provide RN oversight on LPN decisions as required by MVH Program regulations.

Skills

Fraud detection

Data analysis

Report writing

Regulatory compliance

Education

RN licensure

LPN licensure

Associate Degree in Nursing

Job description

WPS Health Solutions seeks a Claims Examiner III, Fraud and Abuse role to identify and report fraudulent or abusive MVH practices. Candidates will review data, develop cases, and coordinate with law enforcement when needed, while ensuring medical necessity aligns with MVH policies.

Position requires RN/LPN licensure with 3+ years clinical practice, DoD clearance eligibility, and ability to work from Madison, WI within 45 miles of the campus; remote work is possible with onsite training as needed.