Claims Examiner III - LPN

Claims Examiner III LPNOur 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 well-supported 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, WisconsinHow 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 QualificationsU.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 CertificationCurrent 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 QualificationsStrong 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 SuccessAbility to interpret medical records, claims data, and utilization patterns.Excellent written communication and professional correspondence skills.Attention to detail and comfort working with large datasets.Commitment to supporting program integrity and reducing fraud, waste, and abuse.Remote Work RequirementsWired (ethernet cable) internet connection from your router to your computer.High speed cable or fiberMinimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at review Remote Worker FAQs for additional information.BenefitsRemote work options availablePerformance bonus and/or merit increase opportunities401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)Competitive paid time offHealth insurance, dental insurance, and telehealth services start DAY 1Professional and Leadership Development ProgramsReview additional benefits: ( We AreWPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses.

We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.Culture Drives Our SuccessWPS' culture is where the great work and innovations of our people are seen, fueled and rewarded.

We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.