Remote RN/LPN Claims Auditor — Fraud & Compliance

WPS Health Solutions; Green Bay (WI); Teletrabalho; USD 25 000 - 35 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Remote work options

Bonus opportunities and merit increase

401(k) with 100% match up to 3%, 50%/2

Health insurance starting Day 1

Resumo da oferta

WPS Health Solutions in Wisconsin is seeking a Claims Examiner III LPN/RN to protect the MVH program by analyzing data, reviewing claims, and identifying fraud or misuse. You will develop and manage investigative cases, assess medical necessity, and prepare audit summaries to support findings.

The role requires RN or LPN licensure with 3+ years of clinical practice and offers remote work options for qualified states. Collaborative work with leadership and external partners is expected.

Qualificações

• U.S. citizenship required due to DoD restrictions.
• RN or LPN licensure current and active.
• 3+ years clinical practice experience.

Responsabilidades

• 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 to determine medical necessity and MVH policy compliance.
• Prepare data formats for physician and peer review; create audit summaries to support findings.
• Identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess data from federal and internal sources to strengthen program controls.
• Work in a fast-paced, high-volume claims processing team.
• Draft professional correspondence with beneficiaries, providers, contractors, and external partners.

Conhecimentos

Data analysis

Clinical experience

Written communication

Attention to detail

Team collaboration

Formação académica

RN licensure or LPN licensure

Associate degree in nursing or equivalent

Ferramentas

MS Excel

Descrição da oferta de emprego

WPS Health Solutions in Wisconsin is seeking a Claims Examiner III LPN/RN to protect the MVH program by analyzing data, reviewing claims, and identifying fraud or misuse. You will develop and manage investigative cases, assess medical necessity, and prepare audit summaries to support findings.

The role requires RN or LPN licensure with 3+ years of clinical practice and offers remote work options for qualified states. Collaborative work with leadership and external partners is expected.