Claims Examiner III, Fraud and Abuse - LPN (Must live in vicinity of Madison, WI WPS campus)

WPS Health Solutions New • Madison, WI

9d • Hybrid

About The Position

This position focuses on identifying, developing, and reporting fraudulent or abusive practices within the Military Veterans Health (MVH) program. The Claims Examiner III provides support to MVH Management Activity, refers cases to law enforcement for action, and ensures that only medically appropriate MVH benefits are paid. U.S. citizenship is required due to Department of Defense restrictions. The role involves working remotely but requires the employee to live within 45 miles of WPS Headquarters in Madison, WI, as occasional onsite work may be required. Training will be conducted onsite at the WPS Corporate Center Building in Madison, WI.

Requirements

• Must live within vicinity of Madison, WI campus location, within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713)
• 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.
• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection.

Nice To Haves

• 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.

Responsibilities

• Generate reports and review data obtained from anti-fraud software to uncover potential fraud and/or abuse situations.
• Develop cases, review statistical data and medical records to identify aberrant patterns, and determine reasons for exceeding norms.
• Compile data in appropriate format for use by Physician/PEER Review.
• Receive and research allegations of fraud and abuse in the MVH program.
• Initiate correspondence to beneficiaries, providers, contractors, TMA, and other outside contacts to disseminate and obtain information.
• Compose letters in a professional, concise manner to educate providers/beneficiaries, obtain information, and refer cases to TMA/law enforcement.
• Evaluate statistics and information from federal and in-house sources for their significance in program controls.
• Perform individual audits and create spreadsheets to summarize findings.
• Perform pre-payment and post-payment review of claims and medical records to determine medical necessity and appropriateness of care, and for compliance with MVH policy.
• Utilize medical knowledge to review claims history and medical records to identify beneficiary overutilization patterns.
• Provide RN oversight on LPN decisions as required by MVH Program regulations.
• Participate in the Quality Management System to maintain MVH International Standard Organization (ISO) certification.

Benefits

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Employee Resource Groups
• Professional and Leadership Development Programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree