Health Management Consultant designing health initiatives for clients at Marsh McLennan Agency. Collaborating with diverse teams to enhance employee well - being and optimize health outcomes.
About the role
- Clinical Investigator responsible for fraud investigations in dental claims management. Analyzing claims data to detect fraud, waste, or abuse with adherence to regulatory compliance.
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
Requirements
- 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
- 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
- Flexible, inclusive and collaborative work environment
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