[Hiring] Special Investigations Unit Investigator @Delta Dental of Michigan

Role 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.

• 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 to 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.

Qualifications

• Bachelor's degree in accounting, business administration, finance, healthcare administration, information technology, or a related field.
• Three years of experience auditing, utilizing analytical tools and software, dental claims billing or review, or as a dental hygienist.
• 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.
• Ability to resolve complex problems using independent judgment.
• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Internal Auditor (CIA) designation is preferred.

Requirements

• 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.