Remote Claims Examiner III – RN/LPN, Fraud & Utilization

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

Ventajas ofrecidas por este puesto de trabajo

Remote work options available

Performance bonus and merit increases

401(k) with generous match

Descripción de la vacante

WPS, a health solutions company, seeks a Claims Examiner III LPN to protect the MVH program by evaluating medical necessity, detecting abuse, and ensuring proper benefit administration. This role blends nursing expertise with data analysis to support audit activities and program integrity.

You will collaborate with leadership and external partners, develop cases, and provide well-supported recommendations, contributing to quality initiatives and DoD compliance.

Formación

• U.S. citizenship required for DoD restrictions.
• RN: ADN or diploma OR LPN: certification; current RN/LPN 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, reports, and medical records to identify potential fraud or aberrant utilization.
• Develop and manage investigative cases, reviewing claims histories and patterns exceeding norms.
• Perform pre-payment and post-payment reviews to determine medical necessity and policy compliance.
• Prepare data for physician and peer review and create audit summaries to support findings.
• Identify overutilization trends and irregular claim activity.

Conocimientos

Data analysis

Claims review

Medical record review

Professional correspondence

Attention to detail

Educación

Associate Degree in Nursing (ADN) or diploma

Licensed Practical Nurse (LPN) certification

Herramientas

MS Excel

Descripción del empleo

WPS, a health solutions company, seeks a Claims Examiner III LPN to protect the MVH program by evaluating medical necessity, detecting abuse, and ensuring proper benefit administration. This role blends nursing expertise with data analysis to support audit activities and program integrity.

You will collaborate with leadership and external partners, develop cases, and provide well-supported recommendations, contributing to quality initiatives and DoD compliance.