Remote Special Investigations Investigator (Fraud)

Deltadentalmi; Okemos (MI); Remote; USD 65,000 - 90,000; Full time

Job summary

Delta Dental of Michigan, Ohio and Indiana is seeking a Special Investigations Unit Investigator to research and report on provider and member activities involving questionable conduct related to treatment patterns, claims, contracts, and licensing.

Candidates must reside in Michigan within commuting distance of the Okemos office for team meetings, training, and collaboration. This is a fully remote role with occasional in-person sessions and anti-fraud initiatives.

Qualifications

• Bachelor's degree in accounting, business administration, finance, healthcare administration, information technology, or related field.
• Three years of auditing experience or use of analytical tools; dental claims knowledge a plus.
• Advanced knowledge of dental terminology and procedure codes; familiarity with ACL, SQL Developer and FAMS.

Responsibilities

• Plan, coordinate, prepare, and perform in-depth provider and member audits.
• Conduct interviews, preserve evidence, and review auditee treatment and financial records.
• Prepare audit reports and communications to ensure contract/license compliance.
• Educate providers and members on contractual requirements for compliance.
• Assist law enforcement in fraud detection and prosecution; respond to subpoenas.
• Recommend system controls and contract improvements to prevent aberrant behavior.
• Develop anti-fraud training programs for corporate staff.

Skills

Analytical thinking

Verbal communication

Written communication

Multitasking

Data mining

Auditing

Attention to detail

Team collaboration

Education

Bachelor's degree in accounting, business admin, finance, healthcare admin, IT, or related field

Tools

Audit Command Language (ACL)

SQL Developer

FAMS (Fraud and Abuse Management System)

Job description

Delta Dental of Michigan, Ohio and Indiana is seeking a Special Investigations Unit Investigator to research and report on provider and member activities involving questionable conduct related to treatment patterns, claims, contracts, and licensing.

Candidates must reside in Michigan within commuting distance of the Okemos office for team meetings, training, and collaboration. This is a fully remote role with occasional in-person sessions and anti-fraud initiatives.