Special Investigations Unit Investigator

Delta Dental of Michigan • Okemos, MI

8d • Remote

About The Position

The Special Investigations Unit Investigator researches and reports on internal and external activities of providers and members involving questionable conduct related to treatment patterns, claim submissions, contract agreements, and state licensing requirements. The position plans and conducts in-depth audits, examines relevant treatment and financial records, and communicates findings to auditees and management to support compliance with contracts and laws.

The investigator also supports fraud detection and enforcement efforts, educates providers, members, and corporate staff, recommends improvements to controls and agreements, and helps develop and maintain relationships with Delta Dental affiliates. The role is fully remote, but candidates must live in Michigan within a reasonable commuting distance of the Okemos, Michigan office for team meetings, collaborative sessions, and training.

Requirements

• Bachelor’s degree in accounting, business administration, finance, healthcare administration, information technology, or a related field, and three years of experience auditing, using analytical tools and software, dental claims billing or review, or working as a dental hygienist; a suitable combination of education, training, or experience will be accepted.
• Advanced knowledge of dental terminology and dental procedure codes.
• Knowledge of common data mining tools, such as Audit Command Language (ACL), SQL Developer, and IBM’s Fraud and Abuse Management System (FAMS).
• Strong verbal and written communication skills.
• Strong organizational and analytical skills.
• Ability to manage multiple assignments with competing deadlines.
• Ability to resolve complex problems using independent judgment.
• Must reside in Michigan within a reasonable commuting distance of the Okemos, Michigan office for team meetings, collaborative sessions, and training.

Nice To Haves

• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Internal Auditor (CIA) designation.

Responsibilities

• Plan, coordinate, prepare, and perform in-depth provider and member audits; research questionable conduct using data extraction and analysis tools and techniques.
• Conduct interviews, request and preserve evidence, and review auditees’ treatment and financial records, controls, and other pertinent records.
• Prepare written communications for auditees and mid- to senior-level management, including requests, audit reports, and general correspondence, to support compliance with contracts and state licenses.
• Educate providers and members about contractual requirements to gain or maintain compliance with participating agreements, client contracts, and applicable laws and regulations.
• Assist law enforcement agencies or attorneys with fraud detection, defense, and prosecution, including responding to subpoenas, preparing documentation, and testifying in administrative or judicial proceedings regarding contract violations.
• Recommend enhancements to system controls and contract agreements to help prevent aberrant behavior.
• Develop training programs and educate corporate staff in anti-fraud activities.
• Assist in implementing, supporting, developing, and maintaining relationships with Delta Dental affiliates.
• Perform other related assigned duties as necessary to complete the primary job responsibilities.

What This Job Offers

• Job Type: Full-time