Remote Claims Examiner III (LPN) – Fraud & Compliance

WPS—A health solutions company; Texas; A distancia; USD 25.000 - 35.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote work options available

Performance bonus/merit increase

401(k) with match

Health insurance

Descripción de la vacante

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 detect unusual utilization patterns.

The position supports collaboration with leadership and external partners, contributes to audits and quality initiatives, and offers remote work options in approved states, with a flexible schedule

Formación

• U.S. citizenship is required due to Department of Defense restrictions.
• Licensed RN or LPN and current licensure.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Responsabilidades

• 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 suitable for Physician and PEER Review; 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.

Conocimientos

Data analysis

Investigation

Medical records review

Auditing

Professional communication

Educación

RN/LPN licensure

Herramientas

MS Excel

Descripción del empleo

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 detect unusual utilization patterns.

The position supports collaboration with leadership and external partners, contributes to audits and quality initiatives, and offers remote work options in approved states, with a flexible schedule