Remote LPN Claims Examiner — Fraud & Compliance Pro

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

Benefits offered by this job

Remote work

Performance bonus

401(k) match

Paid time off

Health insurance

Professional development

Job summary

WPS, a health solutions company, seeks a Claims Examiner III LPN to safeguard the MVH program by identifying and investigating potential fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and ensure proper benefit administration.

This remote-friendly role offers collaboration with internal leadership and external partners, requiring DoD-mandated DoD citizenship and 3+ years of clinical experience. Proficiency in MS Excel is preferred.

Qualifications

• U.S. citizenship is required for this position due to DoD restrictions.
• Active RN or LPN licensure.
• 3+ years clinical practice experience.
• Ability to learn 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 possible fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases, reviewing claims histories and patterns that exceed norms.
• Perform pre-payment and post-payment reviews to determine medical necessity and MVH policy compliance.
• Compile data for physician and PEER review and prepare audit summaries to support findings.
• Identify overutilization trends and irregular claim activity using medical knowledge.
• Conduct audits and assess data from federal and internal sources to strengthen program controls.
• Communicate findings and coordinate with stakeholders when cases are referred to TMA or law enforcement.

Skills

MS Excel

Data analysis

Medical records review

Clinical auditing

Communication

Education

Associate Degree in Nursing (ADN)

Licensed Practical Nursing Program (LPN)

Tools

MS Excel

Job description

WPS, a health solutions company, seeks a Claims Examiner III LPN to safeguard the MVH program by identifying and investigating potential fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and ensure proper benefit administration.

This remote-friendly role offers collaboration with internal leadership and external partners, requiring DoD-mandated DoD citizenship and 3+ years of clinical experience. Proficiency in MS Excel is preferred.