Claims Examiner III - LPN

WPS—A health solutions company • , IN

25d • $22 • Remote

About The Position

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. The role combines clinical expertise with data analysis to evaluate medical necessity, detect unusual utilization patterns, and ensure benefits are administered appropriately. The examiner collaborates with internal leadership and external oversight partners through clear communication, thorough case development, and supported recommendations. The position also contributes to audits and quality initiatives to maintain compliance and strengthen trust in the program.

The position supports U.S. Department of Defense Defense Health Agency contracts and is subject to applicable federal regulations, contract requirements, and WPS policies concerning data security, privacy, confidentiality, and program integrity. Screening and background investigation may be required before access to information systems or sensitive data is granted. U.S. citizenship is required due to Department of Defense restrictions.

Training is Monday through Friday, 8:00 a.m. to 4:00 p.m. Once trained, the scheduled shift is flexible within an eight-hour continuous schedule between 7:00 a.m. and 5:00 p.m. Central Time. Remote work is available only in the listed approved states, and remote workers must have a wired, high-speed cable or fiber internet connection meeting the stated minimum speeds.

Requirements

• U.S. citizenship is required due to Department of Defense restrictions.
• Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensure.
• For RN applicants: an associate degree in nursing or equivalent diploma from an accredited nursing program. For LPN applicants: certification from an accredited practical nursing program.
• At least 3 years of clinical practice experience.
• Ability to learn and apply governing MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.
• Ability to work in a fast-paced, high-volume claims processing team.
• 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 datasets.
• Commitment to supporting program integrity and reducing fraud, waste, and abuse.
• For remote work: a wired Ethernet connection from the router to the computer; high-speed cable or fiber internet; minimum 10 Mbps downstream and 1 Mbps upstream.

Nice To Haves

• Strong experience using MS Excel.
• Bachelor of Science degree in Nursing (RN).
• At least 5 years of clinical practice experience, including at least 2 years in an acute care setting.
• Fluency in a foreign language.
• Fraud prevention or medical auditing background.

Responsibilities

• Analyze anti-fraud software, statistical reports, and medical records to identify potential fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases by 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 for Physician and PEER Review, and create spreadsheets and audit summaries to support findings.
• Use medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess data from federal and internal sources to strengthen program controls.
• 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.
• Contribute to audit activities and quality initiatives, and communicate case findings and recommendations to internal leadership and external oversight partners.

Benefits

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

What This Job Offers

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