Remote Claims Examiner III – MVH Fraud & Compliance

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

Benefits offered by this job

Remote work options available

Performance bonus and/or meritIncrease

401(k) with a 100% match for the first

3% salary match

Competitive paid time off

Health insurance, dental insurance, &

Telehealth services start DAY 1

Job summary

WPS, a health solutions company, seeks a Claims Examiner III LPN to protect the Military Veteran Health program by investigating and preventing fraud, waste, and abuse. The role blends clinical nursing with data analysis to assess medical necessity and detect unusual utilization patterns.

Responsibilities include case development, collaboration with leadership, and preparation of audit summaries. Remote work is available in multiple states; training occurs Monday–Friday 8am–4pm with a flexible

Qualifications

• U.S. citizenship is required for this position due to DoD restrictions.
• Current RN or LPN licensure.
• 3+ years clinical practice experience.
• Ability to learn and apply governing 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 policy compliance.
• Prepare data formats for physician and peer review and create audit summaries to support findings.
• Identify overutilization trends and irregular claim activity using medical knowledge.
• Conduct individual audits and assess data from federal and internal sources to strengthen controls.
• Communicate professionally with beneficiaries, providers, and external partners to obtain information and refer cases as needed.

Skills

Clinical nursing experience

Data analysis

Education

RN or LPN licensure

Nursing degree/diploma

Tools

MS Excel

Job description

WPS, a health solutions company, seeks a Claims Examiner III LPN to protect the Military Veteran Health program by investigating and preventing fraud, waste, and abuse. The role blends clinical nursing with data analysis to assess medical necessity and detect unusual utilization patterns.

Responsibilities include case development, collaboration with leadership, and preparation of audit summaries. Remote work is available in multiple states; training occurs Monday–Friday 8am–4pm with a flexible