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Sun Life · 14 hours ago

Iowa Clinical Investigator Consultant - Must Reside in Iowa

Des Moines, Iowa

Full-time

Hybrid

Mid Level

$54K/yr - $81K/yr

3+ years exp

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse, as well as managing client relationships and ensuring compliance with regulations.

FinanceFinancial ServicesInsurance

Culture & Values

H1B Sponsor Likely

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 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

Clinical interpretationData analysisFraud investigationDental Utilization ManagementRegistered Dental HygienistBusiness writingOral communicationAttention to detailOrganizational skillsInterpersonal skillsAdaptability

Required

Candidate must reside in the state of Iowa

Clinical interpretation of dental radiographs