Remote LPN Claims Auditor – MVH Fraud & Compliance

WPS Health Solutions; Des Moines (IA); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus and merit increase

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the MVH program by identifying, investigating, and preventing fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization, collaborating with leadership and external partners on well-supported conclusions.

The role involves auditing claims, maintaining compliance, and contributing to quality initiatives.

Qualifications

• U.S. citizenship is required for this position.
• Licensed RN or LPN with current licensure.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations and procedures.
• Strong analytical and documentation skills.

Responsibilities

• Analyze data from anti-fraud software, reports, and medical records to identify fraud or abnormal utilization.
• Develop and manage investigative cases reviewing claims histories and patterns.
• Perform pre- and post-payment reviews to determine medical necessity and compliance.
• Prepare data formats for physician and peer review and create audit summaries.
• Identify overutilization trends and irregular claim activity.
• Conduct audits and contribute to program integrity and DoD contract requirements.

Skills

Data analysis

Medical knowledge

Professional communication

MS Excel

Education

RN or LPN licensure

BSN (preferred)

Tools

MS Excel

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the MVH program by identifying, investigating, and preventing fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization, collaborating with leadership and external partners on well-supported conclusions.

The role involves auditing claims, maintaining compliance, and contributing to quality initiatives.