Remote RN/LPN Claims Examiner III – Fraud & Audit

WPS—A health solutions company; Nebraska; Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Performance bonus and/or merit raise

401(k) with company match

Competitive paid time off

Health insurance

Job summary

WPS, a health solutions company, is seeking a Claims Examiner III LPN to protect MVH program integrity by evaluating medical necessity, reviewing claims histories, and analyzing utilization patterns. Remote work is available in approved states; DoD restrictions apply to citizenship.

Ideal candidates will have RN or LPN licensure, 3+ years of clinical practice, and strong MS Excel skills to support data-driven audits and quality initiatives within a fast-paced, high-volume environment.

Qualifications

• Analyze data from anti-fraud software, statistical reports, and medical records to identify fraud, abuse, or aberrant utilization patterns.
• Develop and manage investigative cases, reviewing claims histories and evaluating patterns that exceed norms.
• Perform pre- and post-payment reviews to determine medical necessity, appropriateness of care, and MVH policy compliance.

Responsibilities

• Compile data in formats for physician and peer review; create audit summaries.
• Identify overutilization trends and irregular claim activity using medical knowledge.
• Conduct audits and assess data from federal and internal sources to strengthen program controls.
• Communicate findings clearly with beneficiaries, providers, and external partners.

Skills

Data analysis

Medical record review

Professional communication

Education

RN/LPN licensure

3+ years clinical practice

Tools

MS Excel

Job description

WPS, a health solutions company, is seeking a Claims Examiner III LPN to protect MVH program integrity by evaluating medical necessity, reviewing claims histories, and analyzing utilization patterns. Remote work is available in approved states; DoD restrictions apply to citizenship.

Ideal candidates will have RN or LPN licensure, 3+ years of clinical practice, and strong MS Excel skills to support data-driven audits and quality initiatives within a fast-paced, high-volume environment.