Hybrid Clinical Investigator Consultant

at Sun Life

• Job title: Clinical Investigator Consultant
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: $54,100 - $81,200 per year
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Tampa, United States

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