The Special Investigations Unit (SIU) Analyst acts to safeguard dental benefit programs through the detection and prevention of fraud, waste, and abuse by conducting investigations into suspected insurance fraud.
Responsibilities:
- Conduct full-scale investigations into cases of suspected fraud, waste, and abuse (FWA) involving providers, brokers, clients or enrollees which may require occasional travel. Investigations may involve, but are not limited to, violations of the terms of participation, group contracts, or government regulations.
- Maintain and preserve all audit records, reports, letters, exhibits of findings, and other documentation related to each investigation which may include proposed refunds, disciplinary actions, and educational outreach.
- Obtain and analyze information and data related to the matter(s) under investigation. Identify and evaluate unusual patterns and/or inconsistencies with submitted claims versus clinical documentation received from provider.
- Refer all suspected fraud and/or misrepresentation to law enforcement agencies and assist their investigation by conducting research, providing requested documentation, and collecting evidence in support of such activities or in preparation for referring cases for criminal prosecution, which may include deposition or court testimony.
- Field questions from various sources, including internal and external customers, regarding FWA-related matters.
- Create detailed reports of findings and recommendations based on analysis and research of FWA claims and all case evidence.
- Partner with senior analysts to handle escalated or highly complex cases as needed.
- Analyze current processes and identify existing or potential problems in order to discover new process improvement opportunities.
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Qualifications:
- 2+ w/Bachelor's degree
- Bachelor's Degree and 2+ years of dental insurance fraud claims investigation experience, or Registered Dental Hygiene License and 4+ years of chairside clinical experience, or 6+ years of dental insurance claims investigation experience
- Ability to build trust through organizational savvy and interpersonal skills, allowing for ease of collaboration and communication.
- Aptitude to proactively collect and interpret facts, identify and define vulnerabilities, and initiate opportunities and solutions.
- Ability to learn through embracing challenges, persisting in the face of setbacks, and processing constructive feedback.
- Strong organizational and prioritization skill sets that enable one to set and meet deadlines/time frames.
- Self-motivated and takes initiative. Must be able to work with minimal supervision.
- Proficiency with the Microsoft Office Suite, including Word, Excel, Outlook, Teams, etc.
- Ability to travel for onsite investigations as needed.
Licenses
• RDH - Registered Dental Hygienist. Upon Hire Pref'
Base Pay Information
The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications and ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.
Pay Grade 17. $50,800 - $106,400
Additional Information:
Behind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:
- Competitive base and incentive pay
- 401(k) with robust matching and non-matching contributions
- Rich medical & pharmacy benefits
- 100% employer-paid dental and vision benefits
- Holistic wellbeing program with deep financial incentives
- Generous paid time off plus 12 paid holidays and your birthday off
- Culture of growth and learning: career development; tuition reimbursement; recognition program
- Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
- Social responsibility and volunteer opportunities
- Employee discount program
Fair Chance Ordinances and Criminal Background Considerations
This position requires that the applicant undergo a background check. Qualified applicants with arrest or conviction records will be considered for employment in accordance with any applicable federal, state or local laws, including, but not limited to, the California Fair Chance Act, the Los Angeles County Fair Chance Ordinance, the City of Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and/or New York Corrections Law Article 23-A.
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