Special Investigations Unit Investigator

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

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.