[Hiring] Claims Examiner III @WPS—A health solutions company

Role Description

The Claims Examiner III LPN protects the integrity of the Military Veteran Health (MVH) program by:

• Identifying, investigating, and preventing potential fraud, waste, and abuse.
• Blending clinical expertise with data analysis to evaluate medical necessity.
• Detecting unusual utilization patterns.
• Ensuring benefits are administered appropriately.
• Collaborating with internal leadership and external oversight partners through clear communication.
• Contributing to audit activities and quality initiatives to maintain compliance.

Additional Information:

• Pay rate: At least $21.78/hour based on individual experience and county SCA rates.
• Training Location/Schedule: Monday-Friday 8am~4pm.
• Scheduled Shift: Flexible schedule once trained, 8-hours continual shift between 7:00am CT ~ 5:00pm CT.
• Work Location: Open to remote work in approved states.

How do I know this opportunity is right for me? If you can:

• 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, including reviewing claims histories and evaluating patterns that exceed norms.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity and compliance with MVH policy.
• Compile and prepare data in formats suitable for Physician and PEER Review.
• Utilize medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess the significance of data from federal and internal sources.
• Work in a fast-paced, high-volume claims processing team.
• Initiate and compose professional correspondence with stakeholders to obtain information and refer cases when necessary.

Qualifications

• U.S. citizenship is required for this position due to Department of Defense restrictions.
• Licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) with current licensure.
• 3 or more years clinical practice experience.
• Ability to learn and apply governing MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Requirements

• Strong experience using MS Excel.
• Bachelor of Science Degree in Nursing (RN) preferred.
• 5 or more years clinical practice experience with 2 or more years in an acute care setting preferred.
• Fluent in a foreign language preferred.
• Fraud prevention or medical auditing background preferred.

Benefits

• Remote work options available.
• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% (100% vested immediately).
• Competitive paid time off.
• Health insurance, dental insurance, and telehealth services start DAY 1.
• Professional and Leadership Development Programs.