About the role
WPS, a Madison-based not-for-profit health insurer and federal contractor, is hiring a remote Claims Examiner III (LPN) for its Military Veteran Health program. You will review claims and medical records to spot fraud, waste and abuse and judge medical necessity; remote work is approved in 17 states including Florida and Texas, and U.S. citizenship is required.
Responsibilities
- Analyze anti-fraud software output, statistical reports and medical records to find potential fraud, abuse or unusual utilization
- Develop and manage investigative cases, including claims history reviews and allegation research
- Perform pre-payment and post-payment reviews of claims and records for medical necessity and policy compliance
- Prepare data, spreadsheets and audit summaries for physician and peer review
- Use medical knowledge to identify over-utilization trends and irregular claim activity
- Write professional correspondence to beneficiaries, providers and partners, and refer cases when needed
Requirements
- U.S. citizenship (Department of Defense restriction)
- Current RN or LPN license; LPN candidates need an accredited practical nursing program certification
- 3+ years of clinical practice experience
- Ability to learn and apply MVH regulations, policies and procedures
- Ability to analyze and document medical findings
- Hardwired internet with at least 10 Mbps down and 1 Mbps up
- Preferred: strong Excel skills, BSN, 5+ years of experience with 2+ in acute care, fraud or audit background
What we offer
- Remote work options
- Performance bonus and/or merit increase opportunities
- 401(k) with 100% match on the first 3% and 50% on the next 2%, vested immediately
- Competitive paid time off
- Health and dental insurance and telehealth services from day one
- Professional and leadership development programs