Iowa Clinical Investigator Consultant - Must Reside in Iowa
Core
Retrospective review of paid dental claims and analysis of claims data to identify provider fraud, waste, or abuse.
Role type
Senior clinical investigator (fraud, waste, and abuse)
Builds
Fraud detection and recovery processes for Medicaid, CHIP, Medicare Advantage, and commercial dental plans
Domain
Healthcare insurance + fraud investigation
Required skills
Clinical interpretation of dental radiographs, dental procedures and terminology knowledge, data analysis (utilization reports, trends), regulatory compliance (Medicare, Medicaid), provider relationship management, negotiation, case resolution, documentation
Preferred skills
Licensed Registered Dental Hygienist, Dental Utilization Management or Review experience, general computer software (Excel, Word, Outlook, Adobe)
Responsibilities
Interpret utilization reports to detect patterns of fraud, waste, or abuse; Query data to conduct comprehensive drill down data analysis; Investigate provider and member fraud and abuse; Manage multiple clients and associated provider networks; Work with Dental Directors to assure accurate and defensible clinical decisions; Assist management in overpayment negotiations; Maintain professional relationships with state Medicaid agencies and law enforcement; Track investigative cases in internal database; Prepare recovery documents for processing
Seniority
Senior, hands-on IC
