Special Investigations Unit 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

Job Title

Special Investigations Unit Investigator

Number of Positions

2

Location

Okemos, MI

Location Specifics

Fully Remote

Job Summary

Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training.

At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation.

At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do - from taking charge of our careers, to helping colleagues and lending a hand in the community.

Position Description

Responsible for the research and reporting of internal and external activities of providers and members involved in questionable conduct as it pertains to treatment patterns, claim submissions, contract agreements, and state licensing requirements.

Primary Job Responsibilities

• Plans, coordinates, prepares, and performs in-depth provider and member audits, and researches questionable conduct using data extraction and analysis tools and techniques.
• Conducts interviews, requests and preserves evidence, reviews auditee's treatment and financial records, controls, and other pertinent records.
• Prepares written communications to the auditee and mid to senior level management, including requests, audit reports and general correspondence to ensure compliance with contracts or state licenses.
• Educates providers and members regarding contractual requirements in order to gain or maintain compliance with participating agreements, client contracts, and applicable laws and regulations.
• Provides assistance to law enforcement agencies or attorneys in the detection, defense, and prosecution of fraud, to include responding to subpoenas, preparing documentation, and testifying in administrative or judicial proceedings regarding violations of contracts.
• Makes recommendations to enhance system controls and contract agreements in order assist in preventing aberrant behavior.
• Develops training programs and educates corporate staff in Anti-Fraud activities.
• Assists in implementing, supporting, developing and maintaining relationships with Delta Dental affiliates.
• Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Minimum Requirements

Position requires a bachelor's degree in accounting, business administration, finance, healthcare administration, information technology, or a related field and three years of experience auditing, utilizing analytical tools and software, dental claims billing or review, or as a dental hygienist. Will accept any suitable combination of education, training, or experience.

Position requires advanced knowledge of dental terminology and dental procedure codes; knowledge of common data mining tools, such as Audit Command Language (ACL), SQL Developer and IBM's Fraud and Abuse Management System (FAMS); strong verbal and written communication skills; strong organizational and analytical skills; ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment.

An Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Internal Auditor (CIA) designation is preferred.

The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.