RN/LPN Claims Auditor: Medical Fraud & Compliance (Remote)

WPS Health Solutions; Houston (TX); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus

401(k) with full match

Paid time off

Health insurance

Job summary

WPS Health Solutions is seeking a Claims Examiner III LPN/RN to protect the MVH program by identifying, investigating, and preventing fraud, waste, and abuse. You will blend clinical knowledge with data analysis to evaluate medical necessity and ensure benefits compliance.

The role involves collaboration with leadership and external partners, data-driven case development, and contributing to audits and quality initiatives. DoD restrictions apply, and DoD DoD DoD clearance expectations are noted.

Qualifications

• Ability to learn MVH regulations, policies, and procedures.
• Analyze and document medical findings.
• Strong communication with stakeholders.

Responsibilities

• Identify, investigate, and prevent potential fraud, waste, and abuse in MVH.
• Evaluate medical necessity and utilization patterns for claims.
• Perform pre-payment and post-payment reviews of claims and medical records.
• Compile data for physician and peer review, and create audit summaries.
• Conduct audits and contribute to quality initiatives to strengthen program controls.
• Communicate findings and recommendations to leadership and external partners.

Skills

Data analysis

Clinical experience

Communication

Education

RN licensure

LPN licensure

Tools

MS Excel

Job description

WPS Health Solutions is seeking a Claims Examiner III LPN/RN to protect the MVH program by identifying, investigating, and preventing fraud, waste, and abuse. You will blend clinical knowledge with data analysis to evaluate medical necessity and ensure benefits compliance.

The role involves collaboration with leadership and external partners, data-driven case development, and contributing to audits and quality initiatives. DoD restrictions apply, and DoD DoD DoD clearance expectations are noted.