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

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

Benefits offered by this job

Remote work options

Performance bonus

401(k) with employer match

Paid time off

Health insurance

Professional development programs

Job summary

WPS—A health solutions company is hiring a Claims Examiner III LPN to protect MVH program integrity. The role blends clinical knowledge with data analysis to assess medical necessity, detect unusual utilization, and guide case development for internal and external oversight partners.

Remote work options are available for multiple states, with a standard training schedule and flexible shifts after training. Applicants must be US citizens and hold RN or LPN licensure with 3+ years of clinical

Qualifications

• U.S. citizenship is required due to DoD restrictions.
• RN or LPN licensure is required.
• 3+ years clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Responsibilities

• Analyze data from anti-fraud software and medical records to identify potential fraud and abuse.
• Develop and manage investigative cases reviewing claims histories and patterns.
• Perform pre-payment and post-payment reviews to determine medical necessity and compliance.
• Compile data for physician and peer review and create audit summaries.
• Utilize medical knowledge to identify overutilization trends and irregular activity.
• Conduct audits and assess data from federal and internal sources to strengthen controls.
• Communicate professionally with beneficiaries, providers, and partners to obtain information.

Skills

Data analysis

Professional communication

Attention to detail

Regulatory compliance

Fraud awareness

Education

Associate Degree in Nursing (ADN)

Licensed Practical Nurse (LPN) certification

Tools

MS Excel

Job description

WPS—A health solutions company is hiring a Claims Examiner III LPN to protect MVH program integrity. The role blends clinical knowledge with data analysis to assess medical necessity, detect unusual utilization, and guide case development for internal and external oversight partners.

Remote work options are available for multiple states, with a standard training schedule and flexible shifts after training. Applicants must be US citizens and hold RN or LPN licensure with 3+ years of clinical