Remote LPN Claims Examiner III — Fraud & Compliance

WPS—A health solutions company; Illinois; À distance; USD 25 000 - 35 000; Plein temps

Avantages offerts par ce poste

Remote work options

401(k) with match

Health insurance

Résumé du poste

WPS is seeking a Claims Examiner III LPN to protect the MVH program by identifying fraud and ensuring medical necessity in claims reviews. The role blends clinical expertise with data analysis to investigate utilization patterns and support compliant benefits administration.

Remote work options are available for qualified states; a strong background in Excel, auditing, and medical records is preferred for ongoing audits and program integrity.

Qualifications

• Licensed RN or LPN with current licensure.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations and procedures.
• Strong analytical skills for medical data and claims review.

Responsabilités

• Analyze data from anti-fraud software and medical records to identify abuse.
• Develop and manage investigative cases within MVH.
• Perform pre/post-payment reviews to determine medical necessity and compliance.
• Prepare data and audit summaries for peer review and stakeholders.

Connaissances

Data analysis

Claims processing

Medical auditing

Excel proficiency

Formation

RN or LPN licensure

Outils

MS Excel

Anti-fraud software

Claims management system

Description du poste

WPS is seeking a Claims Examiner III LPN to protect the MVH program by identifying fraud and ensuring medical necessity in claims reviews. The role blends clinical expertise with data analysis to investigate utilization patterns and support compliant benefits administration.

Remote work options are available for qualified states; a strong background in Excel, auditing, and medical records is preferred for ongoing audits and program integrity.