Remote MVH Claims Examiner (RN/LPN) - Fraud & Audit

WPS Health Solutions; Omaha (NE); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus/Merit increase

401(k) with 100% match for the first 3

Health insurance

Dental insurance

Telehealth from day 1

Professional and Leadership Programs

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect MVH program integrity 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 patterns.

You will collaborate with leadership and external partners, contribute to audits and quality initiatives, and help maintain program compliance.

Qualifications

• U.S. citizenship required per DoD restrictions.
• Licensed RN or LPN with current licensure.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.

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 and evaluating patterns that exceed norms.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity and compliance with MVH policy.
• Compile data formats for Physician and 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.
• Collaborate with leadership and external partners to ensure thorough case development and appropriate referrals.

Skills

Data analysis

Medical records review

Regulatory compliance

Written communication

Education

Nursing licensure (RN/LPN)

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 fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns.

You will collaborate with leadership and external partners, contribute to audits and quality initiatives, and help maintain program compliance.