[Remote] Iowa Clinical Investigator Consultant - Must reputed company in Iowa

Note: The job is a remote job and is reputed company to candidates in USA. reputed company U.S. is one of the largest providers of employee and government benefits, helping approximately 50 reputed company Americans reputed company the care and coverage they need. The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse, and will manage the investigative process and maintain relationships with clients.

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 reputed company to fraud, waste and abuse investigation
• Work with and in consultation with reputed company Dental Directors during the investigative process to assure accurate and defensible clinical reputed company
• Responsible for the accuracy of reputed company investigative reputed company and that the reputed company are clinically sound, supported by appropriate and documented authority and defensible
• Assure reputed company audit reputed company are in compliance with Medicare regulations, State reputed company Guidelines, reputed company Office Reference reputed company and plan benefit limitations
• Assist management in overpayment negotiations with providers reputed company to the results and findings of an investigation
• Responsible for the implementation and updating of reputed company client processes reputed company to Fraud, Waste and Abuse
• Maintain the professional relationship with assigned client contacts reputed company to fraud, waste and abuse investigation
• Responsible for reputed company investigation and client reputed company communications to providers for provision of investigative facts and findings
• Responsible for reputed company client facing meetings reputed company to fraud, waste and abuse
• Track reputed company investigative cases in accurate timeline format in internal fraud tracking database
• Have the ability to independently manage workflow to meet business needs, assure contractual obligations for reputed company clients are met and to meet departmental metrics
• Responsible for the development of interdepartmental relationships to assure reputed company issues reputed company to fraud, waste or abuse are identified and appropriately investigated
• Responsible for the preparation and accuracy of recovery documents for processing and assure that they are completed correctly and in a timely fashion
• Responsible for reputed company assigned client contractual reporting requirements reputed company to investigative activity and reputed company
• Maintain professional relationships with market assigned, state reputed company agencies, and state and federal law enforcement agencies
• Assist in the ongoing evaluation of departmental policies and procedures

Skills

• 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
• Licensed Registered Dental Hygienist is preferred
• 3 + years clinical experience and/or reputed company investigative business experience
• Experience in Dental Utilization Management or Review, preferred
• Knowledge of general computer software (reputed company, Word, Outlook, reputed company)

Benefits

• Discretionary annual incentive award based on your individual performance as well as the overall performance of the business
• Generous vacation and sick time
• Market-leading paid family, parental and adoption leave
• Medical coverage
• Company paid life and AD&D insurance
• Disability programs
• Partially paid sabbatical program
• 401(k) employer match
• Stock purchase options
• Employer-funded retirement account
• Flexible, inclusive and collaborative work environment that supports career growth
• Reasonable accommodations to the reputed company physical or mental limitations of otherwise-reputed company individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business

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