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. The Opportunity The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse. The investigator will conduct in‑depth analysis, peer analysis trend analysis and statistical analysis to identify providers whose utilization patterns are outside of the expected norm from their peers in their assigned markets. They will have full responsibility for all contractual obligations for their assigned clients related to fraud, waste or abuse. The investigator is responsible for the professional relationship with assigned clients related to fraud, waste and abuse and is responsible for all aspects of the investigative process from identification, initiation, completion and referral of the investigation as applicable. The investigator will work closely with providers to educate, impose corrective action and reach case resolution, and with clients, managed care organizations, state agencies and law enforcement as required. 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 the accuracy of all investigative decisions and that they 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. Conduct all investigation and client‑related communications to providers for provision of investigative facts and findings. Lead all client‑facing meetings related to fraud, waste and abuse. Track all investigative cases in an accurate timeline format in the internal fraud tracking database. Manage workflow independently to meet business needs and contractual obligations for all clients and departmental metrics. Develop interdepartmental relationships to assure all issues related to fraud, waste or abuse are identified and appropriately investigated. Prepare and ensure the accuracy of recovery documents for processing and timely completion. Handle 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. What you will bring with you Licensed Registered Dental Hygienist is preferred. 3 + years clinical experience and/or related investigative business experience. Experience in Dental Utilization Management or Review is preferred. Preferred skills Knowledge of general computer software (Excel, Word, Outlook, Adobe). Clinical experience and knowledge of dental procedures and terminology is required. Effective oral communication and business writing skills are required. Attention to detail, accuracy and organizational skills are essential. Effective interpersonal skills are essential. Ability to prioritize and adapt to changing priorities is essential. Salary Salary Range: $54,100 - $81,200 At Sun Life, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. EEO Statement We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We encourage applications from qualified individuals from all backgrounds. Accommodations 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. Please email View email address on click.appcast.io to request an accommodation. Discrimination Policy Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances. 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. #J-18808-Ljbffr Crains Cleveland