Fraud Investigator Jobs

About The Position

Requirements

• Bachelor’s degree or equivalent work experience.
• Typing proficiency of 25 words per minute and 10-key proficiency of 105 keystrokes per minute net on a computer keypad.
• Demonstrated knowledge of dental terminology, multiple benefit plans, and products.
• Ability to meet correspondence review timelines.
• Knowledge and understanding of correspondence and fraud and abuse procedures.
• Detail orientation, initiative, analytical skills, and problem-solving abilities.
• Strong organizational skills and ability to prioritize work and meet deadlines.
• Strong reading, verbal, written, and interpersonal communication skills.
• Ability to work independently and as part of a team, interacting professionally with staff, members, providers, and external customers.
• Ability to work under pressure and adapt to changing priorities.
• Proficiency in Moda Health operating systems.
• Proficiency with computer applications such as Microsoft Word and Excel.
• Ability to maintain confidentiality and project a professional business image.
• Ability to communicate positively, patiently, and courteously.
• Ability to report to work on time and daily.
• Reliable, high-speed, hard-wired internet connection to support remote or hybrid work.
• Comfort with being on camera for virtual training and meetings.
• Ability to work beyond the standard workweek, including evenings and occasional weekends, to meet business needs.

Nice To Haves

• Two years of experience as a Claim Support or Customer Service Representative is preferred.

Responsibilities

• Interpret contracts, handbooks, and policies and understand dental health plan processes.
• Research and analyze correspondence and potential fraud and abuse cases related to dental claims, using established guidelines to make decisions.
• Review clinical records for completeness and determine whether a case concerns an administrative policy or a clinical decision.
• Prepare packets for dental consultants or clinicians to review clinical decisions, and respond directly to cases involving administrative policies.
• Independently assess, investigate, and resolve difficult issues using company and industry knowledge and established policies and procedures.
• Organize workload, maintain a constant caseload, and monitor compliance with state and federal response time frames.
• Communicate with members, providers, and attorneys by letter or telephone about claims and Moda Dental Health benefit plan policies.
• Request additional information, such as chart notes or other clinical materials, from providers as needed.
• Enter correspondence and fraud and abuse cases accurately into tracking systems for reporting and auditing.
• Consult management on problem cases and coordinate with other departments to resolve provider correspondence and fraud and abuse questions.
• Ensure fraud and abuse correspondence cases are fully resolved, including contacting other departments when necessary.
• Prepare cases upon receipt and research and respond to dental provider correspondence.
• Perform primary functions of a Dental Claims Support Processor Level II, including adjusting claims based on review outcomes.
• Perform other duties as assigned.

Benefits

• Medical, dental, vision, pharmacy, life, and disability benefits
• 401(k) matching
• Flexible spending account (FSA)
• Employee Assistance Program
• Paid time off
• Company-paid holidays