Remote Special Investigations Investigator - Anti-Fraud

Delta Dental of Michigan; Oregon; Hybrid; USD 80,000 - 110,000; Full time

Job summary

Delta Dental of Michigan, Ohio, and Indiana is seeking a Special Investigations Unit Investigator to conduct in-depth audits of providers and members, analyzing treatment patterns, claims, contracts, and licensing requirements. This role emphasizes anti-fraud activity and requires strong research and reporting skills.

Candidates should reside in Michigan within a reasonable distance of Okemos for meetings and training, with remote flexibility as needed.

Qualifications

• Bachelor's degree plus 3 years auditing or related experience.
• Advanced knowledge of dental terminology and codes; familiarity with ACL, SQL Developer and FAMS.
• Strong verbal and written communication, organizational and analytical skills.
• AHFI, CFE, or CIA designation preferred.

Responsibilities

• Plans, coordinates, prepares, and performs in-depth provider and member audits and researches questionable conduct.
• Conducts interviews, collects evidence, and reviews auditee records and contracts.
• Prepares written communications and audit reports for management to ensure contract compliance.
• Educates providers/members on contractual requirements to ensure compliance with agreements and laws.
• Assists law enforcement or attorneys in detection and prosecution of fraud, including subpoenas and testimony.
• Makes recommendations to enhance system controls and contracts to prevent aberrant behavior.
• Develops training programs and educates staff in anti-fraud activities.
• Maintains relationships with Delta Dental affiliates.
• Performs other related duties as needed.

Skills

Verbal communication

Written communication

Analytical skills

Organizational skills

ACL

SQL Developer

FAMS

Education

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

Tools

ACL

SQL Developer

FAMS

Job description

Delta Dental of Michigan, Ohio, and Indiana is seeking a Special Investigations Unit Investigator to conduct in-depth audits of providers and members, analyzing treatment patterns, claims, contracts, and licensing requirements. This role emphasizes anti-fraud activity and requires strong research and reporting skills.

Candidates should reside in Michigan within a reasonable distance of Okemos for meetings and training, with remote flexibility as needed.