Senior LPN Claims Auditor – MVH Fraud Specialist (Remote)

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

Benefits offered by this job

Remote work options available

Performance bonus and/or merit raise

401(k) with generous company match

Competitive paid time off

Health/dental/telehealth start day 1

Professional development programs

Job summary

WPS, a health solutions company, seeks a Claims Examiner III LPN to protect MVH program integrity by evaluating medical necessity and detecting misuse. You’ll blend clinical and data analysis to review claims, determine appropriate benefits, and support audit activities.

This role offers remote work opportunities across approved US states, with training Monday–Friday 8am–4pm and flexible shift after training. RN or LPN license and 3+ years clinical practice required.

Qualifications

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

Responsibilities

• Analyze data from anti-fraud software and medical records to identify potential fraud and misuse.
• Develop and manage investigative cases reviewing claims histories and patterns.
• Perform pre-payment and post-payment reviews to determine medical necessity.
• Compile data formats for reviewer input and create audit summaries.
• Identify overutilization trends and irregular claim activity.
• Conduct audits and assess data significance to strengthen controls.
• Communicate findings professionally with beneficiaries, providers, and partners.

Skills

Analytical thinking

Communication skills

Attention to detail

MS Excel

Education

RN license

LPN license

Tools

MS Excel

Job description

WPS, a health solutions company, seeks a Claims Examiner III LPN to protect MVH program integrity by evaluating medical necessity and detecting misuse. You’ll blend clinical and data analysis to review claims, determine appropriate benefits, and support audit activities.

This role offers remote work opportunities across approved US states, with training Monday–Friday 8am–4pm and flexible shift after training. RN or LPN license and 3+ years clinical practice required.