Special Investigations Unit Analyst

Delta Dental

3d

About The Position

The Special Investigations Unit (SIU) Analyst acts to safeguard dental benefit programs through the detection and prevention of fraud, waste, and abuse by conducting investigations into suspected insurance fraud. Responsibilities Conduct full-scale investigations into cases of suspected fraud, waste, and abuse (FWA) involving providers, brokers, clients or enrollees which may require occasional travel. Investigations may involve, but are not limited to, violations of the terms of participation, group contracts, or government regulations. Maintain and preserve all audit records, reports, letters, exhibits of findings, and other documentation related to each investigation which may include proposed refunds, disciplinary actions, and educational outreach. Obtain and analyze information and data related to the matter(s) under investigation. Identify and evaluate unusual patterns and/or inconsistencies with submitted claims versus clinical documentation received from provider. Refer all suspected fraud and/or misrepresentation to law enforcement agencies and assist their investigation by conducting research, providing requested documentation, and collecting evidence in support of such activities or in preparation for referring cases for criminal prosecution, which may include deposition or court testimony. Field questions from various sources, including internal and external customers, regarding FWA-related matters. Create detailed reports of findings and recommendations based on analysis and research of FWA claims and all case evidence. Partner with senior analysts to handle escalated or highly complex cases as needed. Analyze current processes and identify existing or potential problems in order to discover new process improvement opportunities.

Requirements

• Bachelor’s Degree and 2+ years of relevant experience
• Ability to build trust through organizational savvy and interpersonal skills, allowing for ease of collaboration and communication
• Aptitude to proactively collect and interpret facts, identify and define vulnerabilities, and initiate opportunities and solutions
• Ability to learn through embracing challenges, persisting in the face of setbacks, and processing constructive feedback
• Strong organizational and prioritization skill sets that enable one to set and meet deadlines/timeframes
• Self-motivated and takes initiative; must be able to work with minimal supervision
• Proficiency with the Microsoft Office Suite, including Word, Excel, Outlook, Teams, etc.
• Ability to travel for onsite investigations as needed

Nice To Haves

• Registered Dental Hygiene License is preferred

Responsibilities

• Conduct full-scale investigations into cases of suspected fraud, waste, and abuse (FWA) involving providers, brokers, clients or enrollees which may require occasional travel. Investigations may involve, but are not limited to, violations of the terms of participation, group contracts, or government regulations.
• Maintain and preserve all audit records, reports, letters, exhibits of findings, and other documentation related to each investigation which may include proposed refunds, disciplinary actions, and educational outreach.
• Obtain and analyze information and data related to the matter(s) under investigation.
• Identify and evaluate unusual patterns and/or inconsistencies with submitted claims versus clinical documentation received from provider.
• Refer all suspected fraud and/or misrepresentation to law enforcement agencies and assist their investigation by conducting research, providing requested documentation, and collecting evidence in support of such activities or in preparation for referring cases for criminal prosecution, which may include deposition or court testimony.
• Field questions from various sources, including internal and external customers, regarding FWA-related matters.
• Create detailed reports of findings and recommendations based on analysis and research of FWA claims and all case evidence.
• Partner with senior analysts to handle escalated or highly complex cases as needed.
• Analyze current processes and identify existing or potential problems in order to discover new process improvement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees