Claims Examiner III - Remote Fraud & Compliance (LPN)

WPS Health Solutions; Atlanta (GA); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Performance bonus

401(k) with match

Paid time off

Health/dental/telehealth starting day

Professional development programs

Job summary

WPS Health Solutions seeks a Claims Examiner III LPN/RN to protect MVH program integrity by investigating and preventing fraud, waste, and abuse. You will analyze medical records, review claims histories, and prepare data for audit and peer review.

Remote work is available in several states, with a flexible schedule after training. The role combines clinical expertise with data analysis to ensure medical necessity and policy compliance, contributing to audits and program improvements in a

Qualifications

• U.S. citizenship required due to DoD restrictions.
• Current RN or LPN licensure.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Responsibilities

• 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, reviewing claims histories and evaluating patterns that exceed norms.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity and MVH policy compliance.
• Compile data in formats suitable for Physician and PEER Review and create spreadsheets and audit summaries to support findings.
• Identify overutilization trends and irregular claim activity using medical knowledge.
• Conduct individual audits and assess data significance from federal and internal sources to strengthen program controls.
• Initiate and compose professional correspondence with beneficiaries, providers, contractors, and external partners.

Skills

Data analysis

Fraud detection

Medical auditing

Education

RN/LPN licensure

Tools

MS Excel

Job description

WPS Health Solutions seeks a Claims Examiner III LPN/RN to protect MVH program integrity by investigating and preventing fraud, waste, and abuse. You will analyze medical records, review claims histories, and prepare data for audit and peer review.

Remote work is available in several states, with a flexible schedule after training. The role combines clinical expertise with data analysis to ensure medical necessity and policy compliance, contributing to audits and program improvements in a