FWA Investigator, Dental Services

Avesis; United States; Remote; USD 55,000 - 110,000; Full time

Job summary

Join a forward-thinking company as a FWA Investigator for Dental Services, where you'll play a crucial role in safeguarding the integrity of dental claims. This dynamic position involves investigating fraud, waste, and abuse within the dental network, utilizing your analytical skills to interpret data and ensure compliance with regulations. You'll work independently and collaboratively, presenting findings to both internal and external parties. With a commitment to ethical standards and community growth, this role offers the chance to make a meaningful impact while enjoying a competitive compensation package and benefits that support your well-being and career development.

Benefits

Excellent medical and dental coverage

401(k) with company match

Tuition assistance

Flexible time off

Life and disability insurance

Qualifications

• Investigate dental fraud cases with accuracy and timeliness.
• Collect and analyze claims data to identify aberrant practices.
• Ensure compliance with federal/state regulations.

Responsibilities

• Conduct thorough investigations of dental claims and billing practices.
• Document findings and report to health plans and regulators.
• Collaborate with stakeholders to address fraud cases.

Skills

Investigative Skills

Data Analysis

Communication Skills

Detail-oriented

Critical Thinking

Education

High School Degree

Bachelor's Degree/Dental Hygienist

5+ years in healthcare fraud investigations

Tools

Microsoft Excel

Microsoft Word

Job description

Join us for an exciting career with the leading provider of supplemental benefits!

Our Promise
Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

The FWA Investigator for Dental Services will utilize claims data reports and dashboards, applicable provider guidelines, and other pertinent sources of information to identify aberrant provider billing practices and patterns. The investigator is responsible for conducting investigations which will include medical record reviews, as well as obtaining any other documentation relevant to an investigation, documenting findings, and reporting to appropriate health plan.

Functional Competencies

• Investigate dental cases of fraud, waste, and abuse timely and accurately of dental network providers
• Develop and deploy effective and efficient investigative strategies for each dental investigation
• Maintain accurate, current and thorough case information in the FWA tracking system
• Collect and secure documentation in relation to dental investigations and prepare summaries of findings
• Present investigative findings to both internal and external parties and produce investigative materials that support
• Identify and refer instances of dental fraud as appropriate to the Health Plan
• Accurately track overpayment recoveries, document and work with collection agency to collect when necessary
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
• Ensure compliance of applicable federal/state regulations and/or contractual obligations
• Report suspected fraud, waste, and abuse to appropriate federal or state government regulators; accurately fill out required reporting templates
• Comply with goals, policies, procedures, and strategic plans as delegated by leadership
• Collaborate with state/federal partners, at the discretion of leadership, to include attendance at workgroups or regulatory meetings

Core Competencies

• Understand dental CPT and procedural coding for dental claim submissions
• Be able to work independently through provider investigations and deploy effective and efficient investigative strategies for each dental investigation
• Be able to collect and secure adequate documentation in relation to dental investigations and prepare summaries of findings
• Understand what constitutes suspected provider fraud, be able to respond appropriately with notifications of key stakeholders within required timeframes
• Ability to coordinate and track overpayment recoveries, document and work with collection agency to collect when necessary
• Data mining skills - collecting, collating, analyzing and interpreting claims data to identify aberrant provider practices
• Understand and apply appropriate applicable federal/Florida state regulations and/or contractual obligations in relation to fraud, waste, and abuse.

Behavioral Competencies

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.
• Initiative: readiness to lead or take action to achieve goals.
• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.
• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.
• Detail-oriented and thorough: managing and completing details of assignments without too much oversight.
• Flexible and responsive: managing new demands, changes, and situations.
• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
• Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.
• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Minimum Qualifications:

• High School Degree or equivalent required. Bachelor's Degree/Dental Hygienist OR 5+ years of experience in healthcare fraud, waste, and abuse dental investigations
• Knowledge of fraud, waste, and abuse regulations
• Intermediate level of proficiency in Microsoft Excel and Word
• 1+ years of experience in health care insurance industry
• 1+ years of experience in dental benefits, dental procedures/CDT coding
• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• National Health Care Anti-Fraud Association (NHCAA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)

FLSA Status: Salaried / Exempt

National Salary Range: $55,790 - $109,040

Bonus Eligible: Annual Incentive Plan (AIP)

How To Stay Safe:

Avesis is aware of fraudulent activity by individuals falsely representing themselves as Avesis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.

Avesis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avesis recruiters will come from a verified email address ending in @Avesis.com.

We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to [e-mail].

To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avesis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
• Life and disability insurance.
• A great 401(k) with company match.
• Tuition assistance, paid parental leave and backup family care.
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
• Employee Resource Groups that advocate for inclusion and diversity in all that we do.
• Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity

At Avsis, We See You. We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic. At Avsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients. We focus on recruiting, training and retaining those individuals that share similar goals. Come Dare to be Different at Avsis, where We See You!