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
Responsible for the accuracy of all investigative decisions
Assure all audit decisions are in compliance with Medicare regulations, State Medicaid Guidelines, and plan benefit limitations
Assist management in overpayment negotiations with providers related to the results and findings of an investigation
Track all investigative cases in accurate timeline format in internal fraud tracking database
Responsible for the development of interdepartmental relationships to assure all issues related to fraud, waste or abuse are identified and appropriately investigated

Licensed Registered Dental Hygienist is preferred
3+ years clinical experience and/or related 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 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

Iowa Clinical Investigator Consultant

Key skills