Remote MVH Claims Examiner III

WPS—A health solutions company; Missouri; Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Performance bonus opportunities

401(k) with match

Job summary

WPS is seeking a Claims Examiner III LPN to protect the MVH program integrity by identifying and preventing fraud, waste, and abuse. This role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization, collaborating with leadership and oversight partners to strengthen program controls.

Remote work is available in approved states, with a starting pay of $21.78/hour based on experience.

Qualifications

• U.S. citizenship required for MVH/DoD restrictions
• Current RN or LPN licensure
• 3+ years clinical practice experience
• Ability to learn MVH regulations
• Ability to analyze and document medical findings

Responsibilities

• Analyze data from anti-fraud software, statistical reports, and medical records to identify potential fraud or aberrant utilization patterns
• Develop and manage investigative cases by reviewing claims histories and researching allegations of fraud and abuse
• Perform pre-payment and post-payment reviews to determine medical necessity and MVH compliance
• Prepare data for Physician and PEER Review and create audit summaries
• Identify overutilization trends and irregular claim activity
• Conduct individual audits and assess data from federal and internal sources
• Work in a fast-paced, high-volume claims processing team
• Compose professional correspondence with beneficiaries, providers, contractors, and external partners

Job description

WPS is seeking a Claims Examiner III LPN to protect the MVH program integrity by identifying and preventing fraud, waste, and abuse. This role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization, collaborating with leadership and oversight partners to strengthen program controls.

Remote work is available in approved states, with a starting pay of $21.78/hour based on experience.