Claims Examiner III Fraud and Abuse LPN

JOB REQUIREMENTS: Description U.S. citizenship is required for this position due to Department of Defense restrictions. Our Claims Examiner III, Fraud and Abuse focuses on identifying, developing, and reporting fraudulent or abusive practices. They provide support to Military Veterans Health (MVH) Management Activity, referral to law enforcement for lead action, and ensure only medically appropriate MVH benefits are paid. Must live within vicinity of Madison, WI campus location, within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) Additional Information Start Date: 10/6/2026 Starting Base Salary: $19.35/hour Training Location/Schedule: Monday-Friday 8am~4 If any, all onsite training will take place at the WPS Corporate Center Building (1717 W. Broadway) in Madison, WI 53713 Scheduled Shift: Flexible schedule once trained, 8-hours shifts 7am-5pm) Work from Home: Currently able to work from home, including training (not considered a permanent remote position). Work Location: This is a remote position, must live within vicinity of Madison, WI campus location, within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713), employees may be required to work at this location at times. How do I know this opportunity is right for me? If you: Can generate reports and review data obtained from anti-fraud software to uncover potential fraud and/or abuse situations. Have developed cases, reviewed statistical data and medical records to identify aberrant patterns, and determined reason for exceeding norms. Enjoy compiling data in appropriate format for use by Physician/PEER Review. Would like to receive and research allegations of fraud and abuse in MVH program. Can initiate correspondence to beneficiaries, providers, contractors, TMA, and other outside contacts to disseminate and obtain information. Can compose letters in a professional, concise manner to educate providers/beneficiaries, obtain information, and refer cases to TMA/law enforcement. Enjoy evaluating statistics and information from federal and in-house sources for their significance in program controls. Like to perform individual audits and create spreadsheets to summarize findings. Can 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. Have utilized medical knowledge to review claims history and medical records to identify beneficiary overutilization patterns. Can provide RN oversight on LPN decisions as required by MVH Program regulations. Would like to participate in Quality Management System to maintain MVH International Standard Organization (ISO) certification. Minimum Qualifications Must live within vicinity of Madison, WI campus... For full info follow application link. Wisconsin Physicians Service Insurance Corporation is an Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities employer. ***** APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/20D5662995074FB6 Qualified females, minorities, and special disabled veterans and other veterans are encouraged to apply.