Remote MVH Claims Examiner & Fraud Investigator (RN/LPN)

WPS Health Solutions; Charleston (SC); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Bonus opportunities

401(k) with match

Job summary

WPS Health Solutions seeks a Claims Examiner III (RN/LPN) to protect the MVH program by identifying and investigating fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns, ensuring benefits are administered appropriately.

This role collaborates with leadership and external oversight partners, contributing to audits and quality initiatives.

Qualifications

• U.S. citizenship is required due to DoD restrictions.
• Valid RN or LPN licensure with current licensure.
• 3+ years of clinical practice experience.

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, reviewing claims histories and researching MVH allegations.
• Perform pre-payment and post-payment reviews to determine medical necessity and MVH policy compliance.
• Compile data for Physician/PEER Review and create audit summaries to support findings.
• 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.
• Work in a fast-paced, high-volume claims processing team.
• Compose professional correspondence with beneficiaries, providers, contractors, and external partners.

Skills

Clinical practice

Data analysis

Medical records review

Professional communication

Education

RN licensure

LPN licensure

Tools

MS Excel

Job description

WPS Health Solutions seeks a Claims Examiner III (RN/LPN) to protect the MVH program by identifying and investigating fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns, ensuring benefits are administered appropriately.

This role collaborates with leadership and external oversight partners, contributing to audits and quality initiatives.