Iowa Clinical Investigator Consultant - Must Reside in Iowa

Sun Life•Des Moines, IA

1d•$54,100 - $81,200•Hybrid

About The Position

Sun Life U.S. is a leading provider of employee and government benefits, serving approximately 50 million Americans. We offer a comprehensive portfolio of benefits including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. DentaQuest, which manages dental and vision benefits for over 33 million Americans, focuses on outcomes-based, cost-effective solutions for various populations, emphasizing prevention and value to improve oral health. Sun Life embraces a hybrid work model, balancing in-office collaboration with remote flexibility for employees in contiguous states plus Alaska. This specific role requires the candidate to reside in the state of Iowa.

Requirements

Must reside in the state of Iowa.
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.
3 + years clinical experience and/or related investigative business experience.
Experience in Dental Utilization Management or Review, preferred.
Knowledge of general computer software (Excel, Word, Outlook, Adobe).

Responsibilities

Responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse.
Conduct in-depth analysis, peer analysis, trend analysis, and statistical analysis to identify providers whose utilization patterns are outside the expected norm.
Have full responsibility for all contractual obligations for assigned clients related to fraud, waste, or abuse.
Manage the professional relationship with assigned clients related to fraud, waste, and abuse.
Oversee all aspects of the investigative process from identification, initiation, completion, and referral.
Work with providers to educate, impose corrective action, and reach case resolution.
Collaborate with clients, managed care organizations, state agencies, and law enforcement as required.
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.
Ensure the accuracy of all investigative decisions, ensuring they 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 the provision of investigative facts and findings.
Responsible for all client-facing meetings related to fraud, waste, and abuse.
Track all investigative cases in an accurate timeline format in the internal fraud tracking database.
Independently manage workflow to meet business needs, assure contractual obligations for all clients are met, and 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.