Supervisor, Focused Review

Job Summary

At Delta Dental of Michigan, Ohio, and Indiana, we improve oral health through benefit plans, advocacy, and community support. As part of the Delta Dental Plans Association, we operate two of the largest dental networks in the nation. Our All In culture encourages career growth, community involvement, and adherence to high standards.

Position Description

Supervises and manages the Provider Auditor Focused Review Special Investigation Unit (SIU), overseeing data research and review, and audit and investigation activities. Ensures all operations comply with corporate and departmental goals and objectives, maintains compliance with applicable standards and policies, and supports continuous improvement in Focused Review processes.

Primary Job Responsibilities

• Supervises and monitors the daily administrative and technical functions of the Focused Review SIU teams, data research and review, and audit and investigation activities to ensure efficient, compliant operations that support departmental and corporate goals and objectives.
• Serves as a resource for audit and research questions, providing guidance to internal and external stakeholders on reporting issues, provider agreements, processing policies, client contracts, and regulatory compliance for both commercial and government programs.
• Supports staff recruitment, onboarding, and development by assisting with interviewing, training, mentoring, and evaluating team members to promote accountability and achievement of individual and team objectives.
• Oversees staff engaged in data research, report development, and analytics, ensuring compliance with regulatory requirements for both commercial and government programs.
• Facilitates communication with law enforcement and legal representatives by supporting the preparation of documentation and responses to subpoenas, and assisting with administrative or judicial proceedings related to fraud, waste, and abuse.
• Builds and maintains collaborative relationships with business partners to provide operational support, clarify requirements, and promote effective use of SIU services and solutions.
• Acts as a liaison for staff and internal departments, providing expertise and interpretation of dental policies, procedure codes, and processing guidelines related to claims adjudication, fraud, waste, and abuse activities.
• Assists in developing and implementing departmental strategies, goals, and objectives to support continuous improvement and operational excellence.
• Supports budget monitoring and resource allocation for the Focused Review SIU teams as directed by management.

Minimum Requirements

• Bachelor’s degree in business administration, criminal justice, or related field.
• Five years of experience conducting investigations, audits, or complex data analysis within the insurance industry.
• Previous leadership experience is preferred, along with experience reviewing claims activity, provider behavior, or group contract compliance.
• Advanced knowledge of the insurance industry operations; strong investigative skills related to fraud, waste, and abuse; proficiency with analytical tools, word processing, spreadsheet, and presentation software skills; strong verbal and written communication skills; strong organizational and analytical skills; the ability to lead investigative teams; the ability to interpret contract language and identify indicators of fraudulent activity; the ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment.
• Professional certifications such as CFE, CIA, AHFI are preferred.