Professional Review Data Analyst

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 — 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.

About the role

Administer data-driven activities by transforming raw data into actionable information to support Professional Review program integrity initiatives.

Responsibilities

• Design, develop, validate, and deploy data-driven analytics, predictive models, reporting solutions, and end-to-end analytical research, including defining objectives, selecting and evaluating data sources, determining methodologies, performing analysis and testing, conducting quality assurance, and interpreting findings.
• Investigate internal and external referrals, perform provider research and preliminary investigative reviews, substantiate referral activity, document work in the appropriate case management system, and analyze provider billing, utilization, and treatment patterns to identify outliers, emerging trends, potential fraud, waste, and abuse activity, and other areas requiring monitoring or intervention.
• Develop recommendations regarding provider placement on or removal from Focused Review; maintain associated provider status, tracking, documentation, and follow-up records; and prepare and send welcome and removal letters and related provider communications.
• Create, maintain, and enhance 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.
• Collect, transform, cleanse, validate, organize, troubleshoot, and resolve data, reporting, database, and system issues to support analysis-ready data, consistent definitions across sources, and data availability, usability, integrity, and reporting effectiveness.
• Track, analyze, and report on denial trends, overpayments, 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.
• Serve 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.
• Lead or support 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.

Requirements

• Bachelor’s degree in computer science, information systems, business administration, or a related field.
• Three years of experience performing data analytics in a business setting (or any suitable combination of education, training, or experience).
• General knowledge of insurance business, claims processing systems, and other business applications.
• Proficiency with data extraction and analysis tools such as Microsoft Excel, Access, PowerPoint, Oracle Discoverer, ACL, and others.
• Strong communication skills and the ability to resolve problems using independent judgment.

Location: Okemos, MI (Hybrid position).