Remote Senior Claims Examiner (RN/LPN) – MVH Fraud

WPS Health Solutions; Charlotte (NC); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Bonus opportunities

401(k) with match

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN to protect MVH program integrity by identifying, investigating, and preventing potential fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns.

The position collaborates with leadership, participates in audits, and supports compliance initiatives. Remote work options are available across several states, with a schedule facilitating efficient

Qualifications

• U.S. citizenship is required due to DoD restrictions.
• Current RN or LPN licensure.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations and procedures.

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, review claims histories, and research allegations of fraud and abuse within MVH.
• Perform pre-payment and post-payment reviews to determine medical necessity and compliance with MVH policy.
• Prepare data formats for Physician and PEER Review and create audit summaries to support findings.
• Identify overutilization trends and irregular claim activity.

Skills

RN/LPN license

Clinical experience

Data analysis

MS Excel

Communication

Education

Associate Degree in Nursing (ADN) or LPN diploma

Tools

MS Excel

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN to protect MVH program integrity by identifying, investigating, and preventing potential fraud, waste, and abuse. The role blends clinical expertise with data analysis to evaluate medical necessity and detect unusual utilization patterns.

The position collaborates with leadership, participates in audits, and supports compliance initiatives. Remote work options are available across several states, with a schedule facilitating efficient