Special Investigations Unit Investigator

Delta Dental Plan of Indiana, Inc.; 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

Special Investigations Unit Investigator# Careers## Special Investigations Unit InvestigatorApply: This is a remote position: Okemos, MI: Full time: Posted Yesterday: JR101506**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.#LI-Remote**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.