Special Investigations Unit Investigator

Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training.

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

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.

Responsibilities

• 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 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.
• Performs other related assigned duties as necessary to complete the responsibilities described above.

Requirements

• Bachelor's degree in accounting, business administration, finance, healthcare administration, information technology, or a related field and three years of experience auditing, utilizing analytical tools and software, dental claims billing or review, or as a dental hygienist. Any suitable combination of education, training, or experience will be considered.
• 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.

Qualifications

An Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Internal Auditor (CIA) designation is preferred.