Iowa Clinical Investigator Consultant - Must Reside in Iowa
Core
Retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse in dental and vision benefits.
Role type
Senior IC clinical investigator (fraud, waste, and abuse)
Builds
Fraud detection and recovery processes for Medicaid, CHIP, Medicare Advantage, and commercial plans
Domain
Healthcare insurance + fraud investigation
Required skills
Clinical interpretation of dental radiographs, dental utilization management, data analysis for fraud detection, provider education and corrective action, regulatory compliance (Medicare/Medicaid), overpayment negotiation, client relationship management, case tracking, policy evaluation
Preferred skills
Licensed Registered Dental Hygienist, 3+ years clinical or investigative experience
Technologies
Excel, Word, Outlook, Adobe, internal fraud tracking database
Responsibilities
Interpret dental radiographs and utilization reports, query data to detect under/over utilization patterns, investigate provider and member fraud, manage multiple client networks, consult with Dental Directors, ensure audit compliance, negotiate overpayments, maintain client and agency relationships, track cases, prepare recovery documents, report outcomes
Seniority
Mid-level, hands-on IC
