Remote MVH Claims Examiner III – Fraud & Compliance (LPN)

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

Benefits offered by this job

Remote work options available

Performance bonus and/or meritIncrease

401(k) with employer match

Competitive paid time off

Health insurance, dental insurance, te

Telehealth services start DAY 1

Professional and LeadershipDevelopment

Careers/Benefits information available

Job summary

WPS—A health solutions company is seeking a Claims Examiner III LPN to protect the MVH program by identifying, investigating, and preventing potential fraud, waste, and abuse. They blend clinical expertise with data analysis to evaluate medical necessity and ensure benefits are administered appropriately.

This role collaborates with leadership and external partners, contributes to audits, and supports quality initiatives to strengthen program integrity.

Qualifications

• U.S. citizenship is required.
• Current RN or LPN licensure in good standing.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations and procedures.
• Ability to analyze and document medical findings.

Responsibilities

• Analyze data from anti-fraud software and medical records to identify fraud, abuse, or aberrant utilization.
• Develop and manage investigative cases reviewing claims histories and patterns.
• Perform pre- and post-payment reviews to determine medical necessity and MVH compliance.
• Prepare data in formats for physician and peer review and create audit summaries.
• Identify overutilization trends and irregular claim activity.
• Conduct audits and assess data from federal and internal sources.
• Work in a fast-paced, high-volume claims environment.
• Draft professional correspondence with beneficiaries, providers, and partners.

Skills

Clinical nursing

Data analysis

Regulatory compliance

Investigation

Communication

Education

RN licensure / LPN licensure

Tools

MS Excel

Job description

WPS—A health solutions company is seeking a Claims Examiner III LPN to protect the MVH program by identifying, investigating, and preventing potential fraud, waste, and abuse. They blend clinical expertise with data analysis to evaluate medical necessity and ensure benefits are administered appropriately.

This role collaborates with leadership and external partners, contributes to audits, and supports quality initiatives to strengthen program integrity.