Remote Healthcare Fraud Investigator

Delta Dental of Michigan; Lansing (MI); Remote; USD 65,000 - 90,000; Full time

Job summary

Delta Dental of Michigan is seeking a Special Investigations Unit Investigator to join our team in Michigan. The role focuses on research and reporting of provider and member activities involving questionable conduct, with emphasis on treatment patterns, claims, contracts, and licensing requirements.

The position involves audits, interviews, evidence handling, and preparing communications for auditees and senior management, supporting compliance and anti-fraud efforts across Delta Dental

Qualifications

• Bachelor’s degree in accounting, business administration, finance, healthcare administration, information technology, or a related field.
• Three years of experience auditing or using analytical tools and software, dental claims billing or review, or experience as a dental hygienist.
• Advanced knowledge of dental terminology and codes; strong verbal and written communication skills.
• AHFI, CFE, or CIA designation is preferred.

Responsibilities

• Plans, coordinates, prepares, and performs in-depth provider and member audits and researches questionable conduct using data tools.
• Conducts interviews, requests and preserves evidence, reviews treatment and financial records and related documents.
• Prepares written communications to auditees and to mid/senior management; ensures contract or licensing compliance.
• Educates providers and members on contractual requirements to maintain compliance.
• Assists law enforcement or attorneys in fraud detection, including subpoenas and testimony.
• Makes recommendations to enhance system controls and contract language.
• Develops training programs and educates staff in anti-fraud activities.
• Maintains relationships with Delta Dental affiliates and supports related duties.
• Performs other duties as assigned to fulfill primary responsibilities.

Skills

Auditing

Analytical thinking

Communication skills

Education

Bachelor's degree in accounting, business administration, finance, healthcare administration, information technology, or related field

Tools

Audit Command Language (ACL)

SQL Developer

IBM Fraud and Abuse Management System (FAMS)

Job description

Delta Dental of Michigan is seeking a Special Investigations Unit Investigator to join our team in Michigan. The role focuses on research and reporting of provider and member activities involving questionable conduct, with emphasis on treatment patterns, claims, contracts, and licensing requirements.

The position involves audits, interviews, evidence handling, and preparing communications for auditees and senior management, supporting compliance and anti-fraud efforts across Delta Dental