Description

U.S. citizenship is required for this position due to Department of Defense restrictions.

Our Claims Examiner III LPN protects the integrity of the Military Veteran Health (MVH) program by identifying, investigating, and preventing potential fraud, waste, and abuse. They blend clinical expertise with data analysis to evaluate medical necessity, detect unusual utilization patterns, and ensure benefits are administered appropriately. This Claims Examiner collaborates with internal leadership and external oversight partners through clear communication, thorough case development, and wellsupported recommendations. Contributing to audit activities and quality initiatives, this role helps maintain compliance and strengthens trust in the program.

*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 We are open to remote work in the following approved states:Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

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, evaluating patterns that exceed norms, and researching allegations of fraud and abuse within the MVH program.

Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity, appropriateness of care, and compliance with MVH policy.

Compile and prepare data in formats suitable for Physician and PEER Review and create spreadsheets and audit summaries to support findings.

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 to strengthen program controls.

Ability to work in a fast past, high volume claims processing team.

Initiate and compose professional correspondence with beneficiaries, providers, contractors, and external partners to obtain information, educate stakeholders, and refer cases to TMA or law enforcement when necessary.

Minimum Qualifications

U.S. citizenship is required for this position due to Department of Defense restrictions.

Licensed Registered Nurse (RN): Associate Degree in Nursing or equivalent diploma from accredited Nursing Program OR Licensed Practical Nurse (LPN): Accredited Practical Nursing Program Certification

Current RN or LPN 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.

Preferred Qualifications

Strong experience using MS Excel.

Bachelor of Science Degree in Nursing (RN).

5 or more years clinical practice experience with 2 or more years in an acute care setting.

Fluent in a foreign language.

Fraud prevention or medical auditing background.

Core Qualities for Success

Ability to interpret medical records, claims data, and utilization patterns.

Excellent written communication and professional correspondence skills.

Attention to detail and comfort working with large

Wisconsin Physicians Service Insurance Corp

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