Professional Review Data Researcher

## Professional Review Data Researcher Apply remote type:
This is a hybrid position, both in-office and remote.locations:
Okemos, MItime type:
Full time posted on:
Posted Todayjob requisition :
JR101400
*
* Job Title:

** Professional Review Data Researcher
** Number of Positions:
** 1
*
* Location:

** Okemos, MI
** Location Specifics:
** Hybrid Position
*
* Job Summary:

** 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:

** To administer data driven activities by transforming raw data into actionable information.
** Primary

Job Responsibilities:

*** Designs, develops, validates, and deploys data-driven analytics, predictive models, reporting solutions, and end-to-end analytical research to support Professional Review program integrity initiatives, including defining objectives, selecting and evaluating data sources, determining methodologies, performing analysis and testing, conducting quality assurance, and interpreting findings.
* Investigates internal and external referrals, performs provider research and preliminary investigative reviews, substantiates referral activity, documents work in the appropriate case management system, and analyzes provider billing, utilization, and treatment patterns to identify outliers, emerging trends, potential fraud, waste, and abuse activity, and other areas requiring monitoring or intervention.
* Develops recommendations regarding provider placement on or removal from Focused Review; maintains associated provider status, tracking, documentation, and follow-up records; and prepares and sends welcome and removal letters and related provider communications.
* Creates, maintains, and enhances dashboards, databases, monitoring reports, analytic tools, scripts, and repeatable processes that support operational oversight, program integrity initiatives, performance measurement, leadership decision-making, recurring reporting, and automated analytical workflows.
* Collects, transforms, cleanses, validates, organizes, troubleshoots, and resolves data, reporting, database, and system issues to support analysis-ready data, consistent definitions across sources, and data availability, usability, integrity, and reporting effectiveness.
* Tracks, analyzes, and reports on denial trends, over payments, provider performance metrics, fraud, waste, and abuse activity, and other key program integrity indicators while supporting program integrity initiatives, audits, regulatory requests, RFP responses, and special projects through data gathering, analysis, response preparation, and recommendations.
* Serves as a consultant and subject matter resource for internal and external stakeholders by translating business needs, reporting questions, research requests, needs assessments, case studies, and related analytic deliverables into clear insights that support monitoring activities, operational improvement, and strategic decision-making.
* Leads or supports Special Investigations Unit and program integrity meetings by developing agendas, documenting meeting minutes, reviewing provider billing and treatment patterns, and tracking follow-up items through completion.#LI-Hybrid
*
* Minimum Requirements:

**…