The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse. The Clinical Investigator will conduct in-depth analysis, peer analysis trend analysis and statistical analysis to identify providers whose utilization patterns are outside of the expected norm from their peers in their assigned markets. They will have full responsibility for all contractual obligations for their assigned clients related to fraud, waste or abuse. The Clinical Investigator is responsible for the professional relationship with assigned clients related to fraud, waste and abuse and is responsible for all aspects of the investigative process from identification, initiation, completion and referral of the investigation as applicable. The Clinical Investigator is responsible for working with providers to educate, impose corrective action and to reach case resolution. The Investigator works closely with clients, managed care organizations, state agencies and law enforcement related to their investigations as required.
PRIMARY JOB 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 State Medicaid Guidelines, DentaQuest Office Reference Manual and plan benefit limitations.
• 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.
• Licensed Registered Dental Hygienist is preferred.
• 3 + years clinical experience and/or related investigative business experience.
• Experience in Dental Utilization Management or Review, preferred
• 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.
• Incumbent must be able to communicate effectively.
• Requires overall light physical effort (up to 25lbs.)
• Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer).
• Ability to travel or move about within and outside serviced facilities required.
• Incumbent works primarily in either a private or shared office environment.