Dental Director - Fraud and Waste

** Become a part of our caring community*
* The Dental Director relies on dental background and reviews dental claims. The Dental Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Dental Director provides dental interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

+ Complete all clinical reviews associated with dental fraud, waste and abuse investigations and create a recommendation on the case direction.

+ Stay up to date on all dental industry standards and provide education and guidance to creating new data tools to review provider outliers

+ Coordinates investigation with law enforcement authorities as well as assembles evidence and documentation to support successful adjudication, where appropriate.

+ Conducts on-site audits of provider records ensuring appropriateness of billing practices.

+ Prepares complex investigative and audit reports and advises executives to develop functional strategies for dental fraud, waste and abuse case on matters of significance.

** Use your skills to make an impact*
* ** WORK STYLE:
** Remote/work le this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

** WORK HOURS** :
Typical business hours are Monday-Friday, 8 hours/day, 5 days/week-- some flexibility might be possible, depending on business needs.

Very minimal travel might be required for trainings, meetings, and/or conferences (less than 5% travel).

** What you need for success!

- Required Qualifications *
* + Doctor of Dental Surgery (DDS) degree or DMD

+ A minimum of five years of experience in a clinical dentist office as a practicing dentist

+ Must hold a clear and active license to practice dentistry (in any US state)

+ Must be comfortable with data analysis/report interpretation

+ Strong computer skills including MS Office desktop applications (Word, Excel, PowerPoint, Visio, Project)

+ Demonstrated competency in written communication skills

+ Solid understanding of process / workflow concepts

+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences

+ Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products

+ Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab

+ The Dental Director conducts clinical reviews of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews and/or condition committees.

** Preferred Qualifications*
* + 5+ years of investigative or auditing experience of dental related claims

+ Knowledge of Medicare regulations

+ Knowledge of Medicaid regulations

+ Knowledge of Commercial insurance regulations

** Additional Information - How We Value You*
* + Benefits starting day 1 of employment

+ Competitive 401k match

+ Generous Paid Time Off accrual

+ Tuition Reimbursement

+ Parental Leave

** Work at Home Requirements*
* WAH requirements:
Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

** Interview Format*
* As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making through on-demand candidate assessments.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.

Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

** SSN Task via Workday*
* Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.

Thrive Together #Work At Home

Work at Home Requirements To ensure Home or Hybrid Home/Office employees'…