DentaQuest · 1 week ago
Florida Clinical Investigator Consultant, DentaQuest
Tampa, FL
Full-time
Hybrid
Mid Level
$54K/yr - $81K/yr
3+ years expDentaQuest is a leader in managing dental and vision benefits for millions of Americans. The Clinical Investigator is responsible for reviewing claims data to identify fraud, waste, or abuse, and managing the investigative process while maintaining professional relationships with clients and providers.
DentalHealth CareHospitalInsuranceMedicalWellness
Responsibilities
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
Responsible for the accuracy of all investigative decisions and that the decisions 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 Responsible for 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 provision of investigative facts and findings
Responsible for all client facing meetings related to fraud, waste and abuse
Track all investigative cases in accurate timeline format in internal fraud tracking database
Have the ability to independently manage workflow to meet business needs, assure contractual obligations for all clients are met and to 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
Qualification
Required
Candidate must reside in the state of Florida
Knowledge of general computer software (Excel, Word, Outlook, Adobe)
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
Preferred
Licensed Registered Dental Hygienist is preferred
3 + years clinical experience and/or related investigative business experience
Experience in Dental Utilization Management or Review, preferred
Benefits
Generous vacation and sick time
Market-leading 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
Company
DentaQuest
DentaQuest is a healthcare firm that provides medical and surgical treatments and services in dentistry.
1001-5000 employees
H1B Sponsorship
DentaQuest has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (1)
2023 (5)
2022 (5)
2021 (7)
2020 (7)
Funding
Current Stage
Late StageTotal Funding
unknownKey Investors
SMILE Health
2023-08-08Non Equity Assistance
2021-10-03Acquired
Leadership Team
Brian Watts
CEO
Shane Patrick, MBA
Managing Client Director (Oklahoma CEO)
Recent News
2025-10-28
2025-10-16
Company data provided by crunchbase