Remote Claims Examiner III (RN/LPN) - MVH Fraud

WPS Health Solutions; Denver (CO); À distance; USD 25 000 - 35 000; Plein temps

Avantages offerts par ce poste

Remote work options

Performance bonus opportunities

401(k) with employer match

Competitive PTO

Résumé du poste

WPS Health Solutions seeks a Claims Examiner III LPN to protect the MVH program by analyzing medical necessity, detecting utilization anomalies, and guiding investigations. This role blends clinical expertise with data analysis in a fast-paced environment and requires DoD eligibility.

Remote work options are available in several states. The successful candidate will collaborate with leadership and external partners to ensure compliant, accurate benefit administration and audit readiness.

Qualifications

• U.S. citizenship required by DoD restrictions.
• Current RN or LPN licensure.
• 3+ years clinical practice experience.
• Able to learn MVH regulations and procedures.
• Able to analyze and document medical findings.

Responsabilités

• 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, review claims histories, evaluate patterns, and research allegations of fraud and abuse within MVH.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity and compliance with MVH policy.
• Compile data in formats for physician and PEER review; create spreadsheets and audit summaries to support findings.
• Use medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess data significance from federal and internal sources to strengthen program controls.
• Work in a fast-paced, high-volume claims processing team.
• Communicate professionally with beneficiaries, providers, contractors, and external partners to obtain information and refer cases as needed.

Connaissances

MS Excel

Fraud prevention

Medical auditing

Formation

RN/LPN licensure

Description du poste

WPS Health Solutions seeks a Claims Examiner III LPN to protect the MVH program by analyzing medical necessity, detecting utilization anomalies, and guiding investigations. This role blends clinical expertise with data analysis in a fast-paced environment and requires DoD eligibility.

Remote work options are available in several states. The successful candidate will collaborate with leadership and external partners to ensure compliant, accurate benefit administration and audit readiness.