Senior LPN Claims Auditor – Fraud & Compliance

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

Benefits offered by this job

Remote work options available

Performance bonus

401(k) with generous match

Health and dental insurance

Job summary

WPS Health Solutions seeks a Claims Examiner III LPN to protect the MVH program by evaluating medical necessity, detecting abnormal utilization, and preventing fraud. The role blends clinical expertise with data analysis and requires collaboration with leadership and external partners.

Eligible candidates have RN/LPN licensure, 3+ years of clinical practice, and the ability to apply MVH regulations. Remote work options are available for eligible states.

Qualifications

• Licensed RN or LPN with current licensure.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations and apply them to cases.
• Strong documentation and data analysis abilities.

Responsibilities

• Analyze data from anti-fraud software and medical records to identify fraud and irregular utilization.
• Develop and manage investigative cases, reviewing claim histories and patterns.
• Perform pre-/post-payment reviews to determine medical necessity and compliance.
• Prepare data formats for peer review and create audit summaries.
• Identify overutilization trends and irregular claim activity.
• Conduct individual audits and use data from federal and internal sources.
• Communicate findings and coordinate with stakeholders and law enforcement when needed.

Education

RN licensure

LPN licensure

Nursing degree or diploma

Tools

MS Excel

Job description

WPS Health Solutions seeks a Claims Examiner III LPN to protect the MVH program by evaluating medical necessity, detecting abnormal utilization, and preventing fraud. The role blends clinical expertise with data analysis and requires collaboration with leadership and external partners.

Eligible candidates have RN/LPN licensure, 3+ years of clinical practice, and the ability to apply MVH regulations. Remote work options are available for eligible states.