Iowa Clinical Investigator Consultant - Must Reside in Iowa at Sun Life

Iowa Clinical Investigator Consultant - Must Reside In Iowa

Sun Life U. S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need.

Denta Quest manages dental and vision benefits for more than 33 million Americans.

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 Clinical Investigator will conduct in‑depth analysis, peer trend analysis and statistical analysis to identify providers whose utilization patterns differ from their peers in assigned markets.

Responsibilities

• Take full responsibility for all contractual obligations for assigned clients related to fraud, waste or abuse.
• Maintain professional relationships with assigned clients and conduct the investigative process from identification to completion and referral as applicable.
• Educate providers, impose corrective action and reach case resolution.
• Work with providers, managed care organizations, state agencies and law enforcement as required.
• Interpret clinical dental radiographs.
• Independently interpret utilization reports to detect fraud, waste or abuse patterns.
• 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.
• Consult with Denta Quest Dental Directors to assure accurate and defensible clinical decisions.
• Ensure all audit decisions comply with Medicare regulations, State Medicaid Guidelines, Denta Quest Office Reference Manual and plan benefit limitations.
• Assist management in overpayment negotiations with providers.
• Implement and update all client processes related to fraud, waste and abuse.
• Track all investigative cases in accurate timeline format in internal fraud tracking database.
• Independently manage workflow to meet business needs and contractual obligations.
• Develop interdepartmental relationships to ensure all issues related to fraud, waste or abuse are investigated properly.
• Prepare and ensure accuracy of recovery documents for processing.
• Maintain professional relationships with market‑assigned, state Medicaid agencies and law enforcement agencies.
• Assist in ongoing evaluation of departmental policies and procedures.

Qualifications

• Licensed Registered Dental Hygienist preferred.
• 3+ years of clinical experience and/or investigative business experience.
• Experience in Dental Utilization Management or Review preferred.
• 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 required.
• Attention to detail, accuracy and organizational skills essential.
• Effective interpersonal skills essential.
• Ability to prioritize and adapt to changing priorities essential.

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 thebrightside@sunlife. com to request an accommodation.

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.

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