Remote Nurse Claims Examiner III – Fraud & Compliance

WPS Health Solutions; Jacksonville (FL); A distancia; USD 25.000 - 35.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote work options

Performance bonus or merit increase

401(k) match

Descripción de la vacante

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, detect unusual utilization patterns, and ensure benefits are administered properly.

The position supports audits, quality initiatives, and collaboration with leadership and external partners.

Formación

• U.S. citizenship is required due to DoD restrictions.
• Current RN or LPN licensure with active status.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations, policies and procedures.

Responsabilidades

• Analyze data from anti-fraud software, statistical reports and medical records to identify potential fraud or abuse.
• Develop and manage investigative cases including reviewing claims histories and researching allegations.
• Perform pre-payment and post-payment reviews to determine medical necessity and compliance with MVH policy.
• Prepare data formats for peer review and create audit summaries to support findings.
• Identify overutilization trends and irregular claims activity.

Conocimientos

Data analysis

Communication

Attention to detail

MS Excel

Clinical knowledge

Educación

RN or LPN licensure

Associate Degree in Nursing or equivalent

Herramientas

Anti-fraud software

Descripción del empleo

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, detect unusual utilization patterns, and ensure benefits are administered properly.

The position supports audits, quality initiatives, and collaboration with leadership and external partners.