Remote LPN Claims Examiner – Fraud & Medical Audit

WPS Health Solutions; Monona (WI); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Bonus opportunities

401(k) match

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to safeguard the Military Veteran Health (MVH) program by identifying potential fraud, waste, and abuse. This role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns, supporting audits and quality initiatives.

The position offers remote work across approved states, a pay rate starting at $21.78 per hour, and opportunities for professional growth as part of a fast-paced,

Qualifications

• U.S. citizenship is required due to federal regulations.
• Licensed RN or LPN with current licensure.
• 3+ years of 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, claims history, and medical records to identify potential fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases, including 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.
• Compile data in formats suitable for physician and peer review; create spreadsheets and audit summaries.
• Identify overutilization trends and irregular claim activity using medical knowledge.
• Conduct individual audits and assess data from federal and internal sources to strengthen program controls.
• Communicate with beneficiaries, providers, contractors, and external partners to obtain information and refer cases when necessary.

Skills

Data analysis

Claims review

Communication skills

Regulatory knowledge

Education

Nursing license (RN or LPN)

Tools

MS Excel

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN to safeguard the Military Veteran Health (MVH) program by identifying potential fraud, waste, and abuse. This role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns, supporting audits and quality initiatives.

The position offers remote work across approved states, a pay rate starting at $21.78 per hour, and opportunities for professional growth as part of a fast-paced,