Remote Medical Claims Integrity Examiner (RN/LPN)

WPS Health Solutions; Columbus (OH); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Bonus opportunities

401(k) match

PTO & holidays

Health coverage from day 1

Professional development

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect MVH program integrity by identifying, investigating, and preventing potential fraud, waste, and abuse. This role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns, collaborating with leadership and external partners.

Remote work options are available for qualified states within the U.S. The position requires U.S.

Qualifications

• US citizenship is required due to DoD restrictions.
• Licensed RN or LPN with current licensure.
• 3+ years clinical practice experience.
• Ability to learn and apply 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 potential fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases, including reviewing claims histories, evaluating patterns that exceed norms, and researching allegations of fraud and abuse within the MVH program.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity, appropriateness of care, and compliance with MVH policy.
• Compile and prepare data in formats suitable for Physician and PEER Review and create spreadsheets and audit summaries to support findings.
• Utilize medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess the significance of data from federal and internal sources to strengthen program controls.
• Ability to work in a fast past, high volume claims processing team.
• Initiate and compose professional correspondence with beneficiaries, providers, contractors, and external partners to obtain information, educate stakeholders, and refer cases to TMA or law enforcement when necessary.

Skills

Data analysis

Fraud detection

Healthcare claims review

Communication skills

Attention to detail

MS Excel

Education

RN or LPN licensure

Nursing degree (ADN/ASN or Diploma)

Tools

MS Excel

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN to protect MVH program integrity by identifying, investigating, and preventing potential fraud, waste, and abuse. This role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns, collaborating with leadership and external partners.

Remote work options are available for qualified states within the U.S. The position requires U.S.