Remote Claims Auditor (LPN/RN) – Fraud & Compliance

WPS—A health solutions company; Georgia; Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus

401(k) with 100% match for first 3%

PTO and health benefits from day 1

Professional development programs

Job summary

WPS, a health solutions company, is seeking a Claims Examiner III LPN to protect MVH program integrity by identifying, investigating, and preventing fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and ensure proper benefits administration.

Remote-friendly opportunity with states approved for remote work. Minimum RN/LPN licensure and 3+ years clinical experience required; DoD regulations apply.

Qualifications

• U.S. citizenship required due to DoD restrictions.
• RN or LPN licensure with current 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, 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 to determine medical necessity and MVH policy compliance.
• Compile data for Physician and PEER Review and create audit summaries to support findings.
• Utilize 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.

Skills

MS Excel

Data analysis

Professional correspondence

Education

RN licensure

LPN licensure

3+ years clinical practice

BSN preferred (RN)

Fraud prevention/medical auditing

Tools

MS Excel

Job description

WPS, a health solutions company, is seeking a Claims Examiner III LPN to protect MVH program integrity by identifying, investigating, and preventing fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and ensure proper benefits administration.

Remote-friendly opportunity with states approved for remote work. Minimum RN/LPN licensure and 3+ years clinical experience required; DoD regulations apply.