Iowa Clinical Investigator Consultant - Must Reside in Iowa

Sun Life•Des Moines, IA

6d•Hybrid

About The Position

Sun Life U.S. is seeking a Clinical Investigator Consultant who must reside in Iowa. This role 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 the expected norm. They will manage contractual obligations for assigned clients related to fraud, waste, or abuse, maintain professional relationships with clients, and oversee the entire investigative process from identification to referral. The role also involves working with providers to educate, impose corrective action, and resolve cases, as well as collaborating with clients, managed care organizations, state agencies, and law enforcement. Sun Life embraces a hybrid work model, and this position requires the candidate to reside in Iowa.

Requirements

3 + years clinical experience and/or related investigative business experience.
Clinical experience and knowledge of dental procedures and terminology is required.
Effective oral communication and business writing skills are required.
Attention to detail, accuracy and organizational skills are essential.
Effective interpersonal skills are essential.
Ability to prioritize and adapt to changing priorities is essential.

Nice To Haves

Licensed Registered Dental Hygienist is preferred.
Experience in Dental Utilization Management or Review, preferred
Knowledge of general computer software (Excel, Word, Outlook, Adobe).

Responsibilities

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 DentaQuest 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, DentaQuest Office Reference Manual and plan benefit limitations.
Assist management in overpayment 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 correctly and in a timely fashion.
Responsible for all assigned client contractual reporting requirements related to investigative activity and outcomes.
Maintain professional relationships with market assigned, state Medicaid agencies, and state and federal law enforcement agencies.
Assist in the ongoing evaluation of departmental policies and procedures.