Special Investigations Unit Investigator

Delta Dental Plan of Michigan, Inc.; United States; Remote; USD 65,000 - 95,000; Full time

Job summary

Delta Dental Plan of Michigan, Inc. is seeking two Special Investigations Unit Investigators to audit providers and members for questionable conduct, with a focus on treatment patterns, claims, contracts, and licensing requirements.

The role involves data-driven audits, interviews, and preparing reports for management to ensure compliance. Applicants should have a bachelor’s degree in a related field and at least three years of auditing or dental claims experience; advanced dental terminology

Qualifications

• Bachelor’s degree in accounting, business administration, finance, healthcare administration, information technology, or related field.
• Three years of experience auditing, using analytical tools, or dental claims review (or as a dental hygienist).
• Advanced knowledge of dental terminology and dental procedure codes.

Responsibilities

• Plan, coordinate, perform in-depth provider and member audits and research questionable conduct.
• Interview, request, preserve evidence, and review auditee records and related data.
• Prepare written communications and audit reports for management to ensure contract and regulatory compliance.
• Educate providers and members on contractual requirements to maintain compliance.
• Assist law enforcement or attorneys in detecting and prosecuting fraud; respond to subpoenas and testify as needed.
• Recommend enhancements to systems and contracts to prevent aberrant behavior.
• Develop training programs on anti-fraud activities and maintain relationships with Delta Dental affiliates.

Skills

Auditing

Analytical skills

Verbal communication

Written communication

Organizational skills

Multitasking

Independent judgment

Education

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

Tools

ACL

SQL Developer

FAMS (Fraud & Abuse Management System)

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.

#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.

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.