Iowa Clinical Investigator Consultant - Reside in Iowa

Overview

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

Denta Quest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse. The Clinical Investigator will conduct in-depth analysis, peer analysis trend analysis and statistical analysis to identify providers whose utilization patterns are outside of the expected norm from their peers in their assigned markets. They will have full responsibility for all contractual obligations for their assigned clients related to fraud, waste and abuse.

The Clinical Investigator is responsible for the professional relationship with assigned clients related to fraud, waste and abuse and is responsible for all aspects of the investigative process from identification, initiation, completion and referral of the investigation as applicable. The Clinical Investigator is responsible for working with providers to educate, impose corrective action and to reach case resolution. The Investigator works closely with clients, managed care organizations, state agencies and law enforcement related to their investigations as required.

• Responsible for clinical interpretation of dental radiographs.
• Independently interpret utilization reports to detect patterns and potential areas of fraud, waste or abuse.
• Query data to conduct comprehensive drill down data analysis to detect patterns and trends of under and over utilization.
• Investigate provider and member fraud and abuse in assigned markets.
• Manage multiple clients and associated provider networks related to fraud, waste and abuse investigation.
• Work with and in consultation with Denta Quest Dental Directors during the investigative process to assure accurate and defensible clinical decisions.
• Responsible for the accuracy of all investigative decisions and that the decisions are clinically sound, supported by appropriate and documented authority and defensible.
• Assure all audit decisions are in compliance with Medicare regulations, State Medicaid Guidelines, Denta Quest Office Reference Manual and plan benefit limitations.
• Assist management in over payment negotiations with providers related to the results and findings of an investigation.
• Responsible for the implementation and updating of all client processes related to Fraud, Waste and Abuse.
• Maintain the professional relationship with assigned client contacts related to fraud, waste and abuse investigation.
• Responsible for all investigation and client related communications to providers for provision of investigative facts and findings.
• Responsible for all client facing meetings related to fraud, waste and abuse.
• Track all investigative cases in accurate timeline format in internal fraud tracking database.
• Have the ability to independently manage workflow to meet business needs, assure contractual obligations for all clients are met and to meet departmental metrics.
• Responsible for the development of interdepartmental relationships to assure all issues related to fraud, waste or abuse are identified and appropriately investigated.
• Responsible for the preparation and accuracy of recovery documents for processing and assure that they are completed…