Remote MVH Claims Auditor (LPN/RN) – Fraud & Compliance

WPS Health Solutions; Indianapolis (IN); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus and/or merit rise

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. The role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization, ensuring benefits are properly administered.

You will collaborate with leadership and oversight partners, contribute to audits and quality initiatives, and help strengthen program integrity.

Qualifications

• U.S. citizenship is required due to Department of Defense restrictions.
• Current RN or LPN licensure.
• 3 or more years clinical practice experience.
• Ability to learn and apply governing 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

Education

Associate Degree in Nursing or equivalent

Licensed Practical Nurse (LPN) Certification

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. The role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization, ensuring benefits are properly administered.

You will collaborate with leadership and oversight partners, contribute to audits and quality initiatives, and help strengthen program integrity.