FWA Investigator, Dental Services

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

Job summary

Join a leading provider of supplemental benefits as an FWA Investigator for Dental Services. In this role, you will utilize claims data to investigate provider billing irregularities, ensuring compliance and addressing issues related to fraud, waste, and abuse within the dental network. With a focus on strategic investigative approaches, you will be instrumental in maintaining the integrity of dental services and collaborating with various stakeholders.

Benefits

Flexible time off

Tuition assistance

401(k) with company match

Excellent medical and dental coverage

Life and disability insurance

Qualifications

• 5+ years of experience in healthcare fraud investigations.
• Knowledge of fraud, waste, and abuse regulations.
• 1+ years of experience in dental procedures/CDT coding.

Responsibilities

• Investigate dental cases of fraud, waste, and abuse.
• Develop investigative strategies for dental investigations.
• Document and report findings to health plans.

Skills

Investigative Strategies

Data Mining

Critical Thinking

Education

High School Degree or equivalent

Bachelor's Degree/Dental Hygienist

Tools

Microsoft Excel

Microsoft Word

Job description

Join to apply for the FWA Investigator, Dental Services role at Avēsis

Join to apply for the FWA Investigator, Dental Services role at Avēsis

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 Avēsis, 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 Avēsis, 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 Avēsis, where We See You!

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Other, Information Technology, and Management

• Industries

  Insurance

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