Remote RN/LPN Claims Auditor for Fraud & Compliance

WPS Health Solutions; Hampton (VA); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus or merit increase

401(k) with 100% match up to 3% and 50

Health, dental, telehealth from Day 1

Professional and LeadershipDevelopment

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the MVH program by identifying and investigating potential fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and ensure benefits are administered properly.

Remote work is possible in approved states; the role requires U.S. citizenship and RN or LPN licensure with 3+ years of clinical experience.

Qualifications

• Analyze data from anti-fraud software and medical records to identify fraud and abuse.
• Develop and manage investigative cases reviewing claims histories and patterns.
• Perform pre-payment and post-payment reviews to determine medical necessity and MVH policy compliance.
• Compile data in formats for physician and peer review and create audit summaries.

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-payment and post-payment reviews to determine medical necessity and MVH policy compliance.
• Prepare data formats for physician reviews and audit summaries.

Skills

Data analysis

MS Excel

Communication

Analytical thinking

Education

RN/LPN licensure

ADN or equivalent nursing diploma

Tools

MS Excel

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the MVH program by identifying and investigating potential fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and ensure benefits are administered properly.

Remote work is possible in approved states; the role requires U.S. citizenship and RN or LPN licensure with 3+ years of clinical experience.