Remote RN/LPN Claims Auditor – MVH Fraud & Compliance

WPS Health Solutions; Newark (NJ); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Performance bonus

401(k) with match

Health insurance starting DAY 1

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the MVH program by investigating fraud, waste, and abuse. The role blends clinical expertise with data analysis to assess medical necessity and detect unusual utilization patterns, ensuring benefits are administered properly.

The role collaborates with leadership and external partners, supports audit activities, and contributes to quality initiatives to strengthen program integrity.

Qualifications

• U.S. citizenship is required for this position due to Department of Defense restrictions.
• Licensed Registered Nurse (RN): Associate Degree in Nursing or equivalent diploma from accredited Nursing Program OR Licensed Practical Nurse (LPN): Accredited Practical Nursing Program Certification
• Current RN or LPN licensure.
• 3 or more years clinical practice experience.
• Ability to learn and apply governing MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.
• Strong experience using MS Excel.
• Bachelor of Science Degree in Nursing (RN).
• 5 or more years clinical practice experience with 2 or more years in an acute care setting.
• Fraud prevention or medical auditing background.

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, evaluating patterns that exceed norms, and researching accusations of fraud and abuse within the MVH program.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity, appropriateness of care, and MVH policy compliance.
• Compile and prepare data in formats suitable for Physician and PEER Review; create spreadsheets and audit summaries to support findings.
• Utilize medical knowledge to identify overutilization trends and irregular claim activity.
• Conduct individual audits and assess the significance of data from federal and internal sources to strengthen program controls.
• Ability to work in a fast past, high volume claims processing team.
• Initiate and compose professional correspondence with beneficiaries, providers, contractors, and external partners to obtain information, educate stakeholders, and refer cases to TMA or law enforcement when necessary.

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN to protect the MVH program by investigating fraud, waste, and abuse. The role blends clinical expertise with data analysis to assess medical necessity and detect unusual utilization patterns, ensuring benefits are administered properly.

The role collaborates with leadership and external partners, supports audit activities, and contributes to quality initiatives to strengthen program integrity.