Remote Claims Examiner III – Fraud & Compliance LPN

WPS Health Solutions; Minneapolis (MN); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Bonus opportunities

401(k) match

Job summary

WPS Health Solutions in Madison, Wisconsin, seeks a Claims Examiner III (LPN/RN) to protect MVH program integrity by reviewing claims and medical records for medical necessity and potential fraud. U.S. citizenship is required for this DoD‑related role.

The examiner analyzes data, investigates unusual utilization patterns, and collaborates with leadership to ensure compliant benefit administration. The job requires strong MS Excel skills, precise documentation, and the ability to manage multiple

Qualifications

• U.S. citizenship is required for this position due to DoD restrictions.
• Licensed RN or LPN with active licensure is required.
• 3+ years of clinical practice experience.

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, including 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 and prepare data in formats for Physician and PEER Review and create audit summaries.

Skills

MS Excel

Data analysis

Medical records review

Education

RN Associate Degree

LPN Certification

Tools

Claims software

Audit tools

Job description

WPS Health Solutions in Madison, Wisconsin, seeks a Claims Examiner III (LPN/RN) to protect MVH program integrity by reviewing claims and medical records for medical necessity and potential fraud. U.S. citizenship is required for this DoD‑related role.

The examiner analyzes data, investigates unusual utilization patterns, and collaborates with leadership to ensure compliant benefit administration. The job requires strong MS Excel skills, precise documentation, and the ability to manage multiple