Iowa Clinical Investigator Consultant - Must Reside in Iowa

Sun Life•Des Moines, IA

22h•$54,100 - $81,200•Hybrid

About The Position

The Clinical Investigator conducts retrospective reviews of paid claims and analyzes claims data to identify provider fraud, waste, or abuse. The role includes in-depth, peer, trend, and statistical analysis to identify providers whose utilization patterns are outside expected norms in assigned markets. The investigator has responsibility for contractual obligations and professional client relationships related to fraud, waste, and abuse, and manages investigations from identification and initiation through completion and referral as applicable. The role also involves educating providers, imposing corrective action, and reaching case resolution, while coordinating with clients, managed care organizations, state agencies, and law enforcement as needed. The position requires clinical interpretation of dental radiographs, independent analysis of utilization reports and queried data, and management of multiple clients and provider networks. The investigator works with DentaQuest Dental Directors to ensure clinical decisions are accurate, documented, compliant, and defensible. Responsibilities also include provider and client communications, client-facing meetings, case tracking, recovery documentation, contractual reporting, and contributing to departmental policies and procedures. The candidate must reside in Iowa. Sun Life describes its work model as hybrid, balancing in-office collaboration with virtual work.

Requirements

At least 3 years of clinical experience and/or related investigative business experience.
Clinical experience and knowledge of dental procedures and terminology.
Effective oral communication and business writing skills.
Attention to detail, accuracy, and organizational skills.
Effective interpersonal skills.
Ability to prioritize and adapt to changing priorities.
Must reside in Iowa.

Nice To Haves

Licensed Registered Dental Hygienist.
Experience in Dental Utilization Management or Review.
Knowledge of general computer software, including Excel, Word, Outlook, and Adobe.

Responsibilities

Interpret dental radiographs clinically.
Independently interpret utilization reports to detect patterns and potential fraud, waste, or abuse.
Query data and conduct comprehensive drill-down analysis to identify patterns and trends in underutilization and overutilization.
Investigate provider and member fraud and abuse in assigned markets.
Manage multiple clients and associated provider networks related to fraud, waste, and abuse investigations.
Work with DentaQuest Dental Directors during investigations to support accurate and defensible clinical decisions.
Ensure investigative decisions are accurate, clinically sound, documented with appropriate authority, and defensible.
Ensure audit decisions comply with Medicare regulations, State Medicaid Guidelines, the DentaQuest Office Reference Manual, and plan benefit limitations.
Assist management with overpayment negotiations with providers based on investigation findings.
Implement and update client processes related to fraud, waste, and abuse.
Maintain professional relationships with assigned client contacts.
Communicate investigative facts and findings to providers and manage investigation- and client-related communications.
Lead client-facing meetings related to fraud, waste, and abuse.
Track investigative cases accurately and chronologically in the internal fraud tracking database.
Independently manage workflow to meet business needs, contractual obligations, and departmental metrics.
Develop interdepartmental relationships to identify and appropriately investigate fraud, waste, or abuse issues.
Prepare accurate recovery documents and ensure they are processed correctly and on time.
Complete assigned client contractual reporting requirements related to investigative activity and outcomes.
Maintain professional relationships with assigned markets, state Medicaid agencies, and state and federal law enforcement agencies.
Assist in the ongoing evaluation of departmental policies and procedures.

Benefits

Generous vacation and sick time.
Paid family, parental, and adoption leave.
Medical coverage.
Company-paid life and AD&D insurance.
Disability programs.
Partially paid sabbatical program.
401(k) employer match.
Stock purchase options.
Employer-funded retirement account.
Flexible, inclusive, and collaborative work environment that supports career growth.
Discretionary annual incentive award based on individual and business performance.