As an Insurance Fraud Analyst on our Special Investigations Unit (SIU, you'll play an integral role in acting to safeguard dental benefit programs from fraud, waste, and abuse by assessing provider ability and actions to meet the terms of participation in provider networks and state/federal requirements. You will be responsible for performing audits and reviews of dental records, assisting in special investigations, and providing support in fulfilling requests from various enforcement agencies.

This is a hybrid position which involves coming to the associate office as needed.

Responsibilities:

• Conducts full-scale investigations into cases of suspected fraud, waste, and abuse (FWA) involving providers, brokers, clients or enrollees which may require occasional travel. Investigations may involve, but are not limited to, violations of the terms of participation, group contracts, or government regulations.
• Maintain and preserve all audit records, reports, letters, exhibits of findings, and other documentation related to each investigation which may include proposed refunds, disciplinary actions, and educational outreach.
• Obtain and analyze information and data related to the matter(s) under investigation.
• Identify and evaluate unusual patterns and/or inconsistencies with submitted claims versus clinical documentation received from provider.
• Refer all suspected fraud and/or misrepresentation to law enforcement agencies and assist their investigation by conducting research, providing requested documentation, and collecting evidence in support of such activities, or in preparation for referring cases for criminal prosecution, which may include deposition or court testimony.
• Field questions from various sources, including internal and external customers, regarding FWA-related matters.
• Create detailed reports of findings and recommendations based on analysis and research of FWA claims and all case evidence.
• Partner with senior analysts to handle escalated or highly complex cases as needed.
• Analyze current processes and identify existing or potential problems in order to discover new process improvement opportunities.
• Perform other duties as requested or assigned.

• 2+ years of dental insurance fraud claims investigation experience, or Registered Dental Hygienist License and 4+ years of chairside clinical experience, or 6+ years of dental insurance claims investigation experience.
• Bachelors degree preferred.
• Ability to build trust through organizational savvy and interpersonal skills, allowing for ease of collaboration and communication.
• Aptitude to proactively collect and interpret facts, identify and define vulnerabilities, and initiate opportunities and solutions.
• Ability to learn through embracing challenges, persisting in the face of setbacks, and processing constructive feedback.
• Strong organizational and prioritization skill sets that enable one to set and meet deadlines/time frames.
• Self-motivated and takes initiative. Must be able to work with minimal supervision.
• Proficiency with the Microsoft Office Suite, including Word, Excel, Outlook, Teams, etc.