Remote RN/LPN Claims Examiner — Fraud & Compliance

WPS Health Solutions; Kansas City (MO); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Bonus opportunities

401(k) with match

Health insurance

Dental insurance

Paid time off

Job summary

WPS Health Solutions seeks a Claims Examiner III LPN/RN to protect the MVH program by identifying, investigating, and preventing potential fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns.

This role requires U.S. citizenship, RN or LPN licensure, and 3+ years of clinical practice. The position offers remote work options within approved states and operates within a DoD contract context.

Qualifications

• US citizenship required due to DoD restrictions.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.

Responsibilities

• Analyse data from anti-fraud software, reports, and medical records to identify fraud or aberrant utilization.
• Develop and manage investigative cases, review claims histories, and research allegations of fraud and abuse.
• Perform pre-payment and post-payment reviews of claims to determine medical necessity and compliance with MVH policy.
• Prepare data formats for physician and peer review; create spreadsheets and audit summaries.

Skills

MS Excel

Education

Associate Degree in Nursing (ADN)

RN/LPN licensure

Tools

MS Excel

Job description

WPS Health Solutions seeks a Claims Examiner III LPN/RN to protect the MVH program by identifying, investigating, and preventing potential fraud, waste, and abuse. You will blend clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns.

This role requires U.S. citizenship, RN or LPN licensure, and 3+ years of clinical practice. The position offers remote work options within approved states and operates within a DoD contract context.