Special Investigations Unit Investigator

Overview

This role involves research and reporting of internal and external activities of providers and members involved in questionable conduct related to treatment patterns, claim submissions, contract agreements, and state licensing requirements.

The position requires candidates to reside in Michigan within a reasonable commuting distance of the Okemos, MI office for team meetings, collaborative sessions, and training. Work is fully remote.

Responsibilities

• Plan, coordinate, prepare, and perform in-depth provider and member audits, including research of questionable conduct using data extraction and analysis tools and techniques.
• Conduct interviews; request and preserve evidence; review auditee treatment and financial records; and review controls and other pertinent records.
• Prepare written communications to auditees and mid to senior level management, including requests, audit reports, and general correspondence to support compliance with contracts or state licenses.
• Educate providers and members on contractual requirements to gain or maintain compliance with participating agreements, client contracts, and applicable laws and regulations.
• Assist law enforcement agencies or attorneys in the detection, defense, and prosecution of fraud, including responding to subpoenas, preparing documentation, and testifying in administrative or judicial proceedings regarding violations of contracts.
• Make recommendations to enhance system controls and contract agreements to help prevent aberrant behavior.
• Develop training programs and educate corporate staff in Anti-Fraud activities.
• Assist in implementing, supporting, developing, and maintaining relationships with dental plan affiliates.
• Perform other related duties as assigned to support the primary responsibilities.

Requirements

• Bachelor’s degree in accounting, business administration, finance, healthcare administration, information technology, or a related field.
• Three years of experience auditing, utilizing analytical tools and software, dental claims billing or review, or as a dental hygienist.
• Will accept any suitable combination of education, training, or experience.
• Advanced knowledge of dental terminology and dental procedure codes.
• Knowledge of common data mining tools, such as Audit Command Language (ACL), SQL Developer, and IBM’s Fraud and Abuse Management System (FAMS).
• Strong verbal and written communication skills.
• Strong organizational and analytical skills.
• Ability to manage multiple assignments with competing deadlines.
• Ability to resolve complex problems using independent judgment.

Preferred Qualifications

• Accredited Healthcare Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Certified Internal Auditor (CIA)

Location

• Okemos, MI
• Fully Remote (with requirement to reside in Michigan within a reasonable commuting distance of the Okemos, MI office for team meetings, collaborative sessions, and training)

Compensation & Benefits

• Equal employment and advancement opportunity within the organization’s business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.