Remote Claims Examiner III - Fraud & Compliance (LPN/RN)

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

Benefits offered by this job

Remote work options available

Performance bonus and merit increase

401(k) with employer match

Competitive PTO

Health and dental insurance starting 1

Professional development programs

Job summary

WPS, a health solutions company, is seeking a Claims Examiner III LPN to protect MVH program integrity by auditing claims, evaluating medical necessity, and identifying fraud. The role blends clinical knowledge with data analysis and requires U.S.

citizenship due to DoD restrictions, with remote work available in approved states. Monday–Friday training and flexible shift options follow 7:00am–5:00pm CT hours.

Qualifications

• Must be a licensed RN or LPN and have 3+ years clinical experience.
• Must learn and apply MVH regulations, policies, and procedures.
• Strong data analysis and documentation of medical findings.

Responsibilities

• Analyze data from anti-fraud software and medical records to identify fraud or abuse.
• Develop and manage investigative cases reviewing claims histories and patterns.
• Perform pre- and post-payment reviews to determine medical necessity and policy compliance.
• Prepare data formats for physician/peer review and create audit summaries.
• Identify overutilization trends and irregular claim activity.
• Conduct audits and assess data from federal and internal sources to strengthen controls.
• Communicate with beneficiaries, providers, and external partners as needed.

Skills

Attention to detail

Professional communication

Education

RN or LPN licensure

Associate Degree in Nursing or equivalent

Current RN or LPN licensure

Tools

MS Excel

Job description

WPS, a health solutions company, is seeking a Claims Examiner III LPN to protect MVH program integrity by auditing claims, evaluating medical necessity, and identifying fraud. The role blends clinical knowledge with data analysis and requires U.S.

citizenship due to DoD restrictions, with remote work available in approved states. Monday–Friday training and flexible shift options follow 7:00am–5:00pm CT hours.