Senior Claims Auditor (RN/LPN) - Remote, Fraud Prevention

WPS Health Solutions; Marion (IL); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options

Performance bonus

401(k) with company match

Generous paid time off

Health insurance

Job summary

WPS Health Solutions is hiring a Claims Examiner III (RN/LPN) to protect the MVH program by identifying fraud and ensuring proper benefit administration. You will blend clinical insight with data analysis to review claims, detect unusual utilization, and prepare thorough recommendations for leadership and external oversight partners.

The role involves auditing claims, collaborating with internal teams, and supporting DoD contract requirements, with remote work options available in multiple

Qualifications

• U.S. citizenship is required for this position due to DoD restrictions.
• Licensed RN (ADN or equivalent) or LPN licensure with current licensure.
• 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, reports, and medical records to identify potential fraud.
• Develop and manage investigative cases, review claims histories and patterns.
• Perform pre-payment and post-payment reviews to determine medical necessity and compliance.
• Prepare data formats for Physician/PEER Review and create audit summaries.
• Identify overutilization trends and conduct audits using federal and internal data.
• Communicate with beneficiaries, providers, and partners to obtain information.

Skills

Analytical thinking

Attention to detail

Professional communication

Team collaboration

Medical auditing

Education

RN licensure or LPN licensure

ADN or nursing diploma

Tools

MS Excel

Job description

WPS Health Solutions is hiring a Claims Examiner III (RN/LPN) to protect the MVH program by identifying fraud and ensuring proper benefit administration. You will blend clinical insight with data analysis to review claims, detect unusual utilization, and prepare thorough recommendations for leadership and external oversight partners.

The role involves auditing claims, collaborating with internal teams, and supporting DoD contract requirements, with remote work options available in multiple