Iowa Clinical Investigator Consultant - Must Reside in Iowa

Job Description Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK. Candidate must reside in the state of Iowa. 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. Ensure all investigative decisions are clinically sound, supported by appropriate and documented authority and defensible. Assure all audit decisions are in compliance with Medicare regulations, State Medicaid Guidelines, DentaQuest Office Reference Manual and plan benefit limitations. Assist management in overpayment negotiations with providers related to the results and findings of an investigation. Implement and update all client processes related to Fraud, Waste and Abuse. Maintain the professional relationship with assigned client contacts related to fraud, waste and abuse investigation. Communicate all investigation findings to providers for provision of investigative facts and findings. Represent clients in meetings related to fraud, waste and abuse. Track all investigative cases in an accurate timeline format in the internal fraud tracking database. Independently manage workflow to meet business needs, assure contractual obligations for all clients are met and meet departmental metrics. Develop interdepartmental relationships to identify and appropriately investigate fraud, waste or abuse issues. Prepare and accurately complete recovery documents for processing. Fulfill 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. Assist in the ongoing evaluation of departmental policies and procedures. Qualifications Licensed Registered Dental Hygienist preferred. 3+ years clinical experience and/or related investigative business experience. Experience in Dental Utilization Management or Review preferred. Preferred Skills Knowledge of general computer software (Excel, Word, Outlook, Adobe). Clinical experience and knowledge of dental procedures and terminology required. Effective oral communication and business writing skills required. Attention to detail, accuracy and organizational skills essential. Effective interpersonal skills essential. Ability to prioritize and adapt to changing priorities essential. Salary Salary Range: $54,100 - $81,200 Additional compensation may include a discretionary annual incentive award based on individual and overall business performance. Equal Employment Opportunity All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local laws, including fair‑chance ordinances. #J-18808-Ljbffr