Dental Insurance Fraud Analyst - Special Investigations Unit

Delta Dental of California
$50,800 - $106,400
dental insurance
United States, Pennsylvania, Camp Hill
Dec 20, 2024
JOB DESCRIPTION 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. QUALIFICATIONS 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. Base Pay Information The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity. Pay Grade 17. $50,800 - $106,400 ABOUT THE TEAM At Delta Dental, we're behind millions of smiles and counting. For over 68 years, we've served our communities by increasing access to affordable, quality care - but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building equitable programs that offer opportunities for advancement, create meaningful connections and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all. We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment focused on teamwork and camaraderie. Discover the smiling faces behind Delta Dental and experience our values and culture in action by connecting with us on social media. Follow Delta Dental Ins. on Facebook and Instagram, #LifeatDDins on Facebook and Instagram, Delta Dental Ins. on Twitter and Delta Dental Ins. on LinkedIn. If you've got an appetite for innovation and want to be a part of a team that's transforming the future of health care, join us! Since 1955, we have offered comprehensive, high-quality oral health care benefits to millions of enrollees and built the strongest network of dental providers in the country. The Delta Dental of California network includes affiliates Delta Dental Insurance Company; Delta Dental of Pennsylvania; Delta Dental of New York, Inc.; Delta Dental of the District of Columbia; Delta Dental of Delaware, Inc.; and Delta Dental of West Virginia, providing dental benefits to more than 31 million people across 15 states, the District of Columbia, Puerto Rico and the Virgin Islands. The company and its affiliates are part of Delta Dental Plans Association (DDPA), a not-for-profit national association based in Oak Brook, Illinois. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories. We offer vision coverage through DeltaVision in 15 states and the District of Columbia. Collectively, we deliver benefits to more Americans than any other dental insurance company. Delta Dental is an equal opportunity employer. We are committed to building and maintaining a diverse and inclusive workplace for all employees. Applicants will not be discriminated against because of race, color, religion, creed, national origin, ancestry, citizenship status, sex (including pregnancy), sexual orientation, gender or identity expression, age, disability, marital status, medical status, veteran status or any other status protected under federal, state, or local law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico, District of Columbia (Washington D.C.) or other US Territories at this time. Proof of eligibility to work in the United States must be provided if selected for hire. Delta Dental includes: Delta Dental of California, Delta Dental Insurance Company, Delta Dental of Pennsylvania, and Delta Dental of New York If You Are A Current Employee Click Here* To Apply