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 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.
Preferred Qualifications
- 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.
Remote Work Requirements
- 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 (can be checked at https://speedtest.net).
- Please review Remote Worker FAQs for additional information.
Benefits
- Bargaining Unit position
- 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
- Review additional benefits: (https://www.wpshealthsolutions.com/careers/)
Who We Are
WPS, 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 Success
WPS’ 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.
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WPS Health BlogThis position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s). As such, the role is subject to all applicable federal regulations, DoD contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. DoD contractors and their personnel are subject to screening and background investigation prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services.
