Job Title: Special Investigations Unit Investigator Number of Positions: 2 Location: Okemos, MI Location Specifics: Fully Remote Job Summary: Candidates must reside in Michigan within a reasonable commuting distance of our Okemos, MI office for team meetings, collaborative sessions, and training. At Delta Dental of Michigan, Ohio, and Indiana we work to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by investing in initiatives that build healthy, smart, vibrant communities. We are one of the largest dental plan administrators in the country, and are part of the Delta Dental Plans Association, which operates two of the largest dental networks in the nation. At Delta Dental, we celebrate our All In culture. It’s a mindset, feeling and attitude we wrap around all that we do – from taking charge of our careers, to helping colleagues and lending a hand in the community. Position Description: Responsible for the research and reporting of internal and external activities of providers and members involved in questionable conduct as it pertains to treatment patterns, claim submissions, contract agreements, and state licensing requirements. Primary Job Responsibilities: Plans, coordinates, prepares, and performs in-depth provider and member audits, and researches questionable conduct using data extraction and analysis tools and techniques. Conducts interviews, requests and preserves evidence, reviews auditee’s treatment and financial records, controls, and other pertinent records. Prepares written communications to the auditee and mid to senior level management, including requests, audit reports and general correspondence to ensure compliance with contracts or state licenses. Educates providers and members regarding contractual requirements in order to gain or maintain compliance with participating agreements, client contracts, and applicable laws and regulations. Provides assistance to law enforcement agencies or attorneys in the detection, defense, and prosecution of fraud, to include responding to subpoenas, preparing documentation, and testifying in administrative or judicial proceedings regarding violations of contracts. Makes recommendations to enhance system controls and contract agreements in order assist in preventing aberrant behavior. Develops training programs and educates corporate staff in Anti-Fraud activities. Assists in implementing, supporting, developing and maintaining relationships with Delta Dental affiliates. Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above. #LI-Remote Minimum Requirements: Position requires a bachelor's degree in accounting, business administration, finance, healthcare administration, information technology, or a related field and three years of experience auditing, utilizing analytical tools and software, dental claims billing or review, or as a dental hygienist. Will accept any suitable combination of education, training, or experience. Position requires advanced knowledge of dental terminology and dental procedure codes; knowledge of common data mining tools, such as Audit Command Language (ACL), SQL Developer and IBM’s Fraud and Abuse Management System (FAMS); strong verbal and written communication skills; strong organizational and analytical skills; ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment. An Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Internal Auditor (CIA) designation is preferred. The company will provide equal employment and advancement opportunity within the context of its unique business environment without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance. Delta Dental of Michigan, Ohio, and Indiana has been a dental benefits leader for more than 60 years, and today with our affiliates, we are one of the largest dental plan administrators in the country. It’s our mission to improve oral health through benefit plans, advocacy and community support, and we amplify this mission by making investments that build healthy, smart, vibrant communities. We celebrate diverse thought and foster a culture where employees go All In – for the company, themselves, their colleagues and their communities. Employees are offered a comprehensive benefits package that includes medical, dental and vision coverage, short- and long-term disability, life insurance, 401(k) savings plans, flexible spending accounts, and tuition reimbursement or educational assistance. Employees are also eligible for annual incentive compensation based on annual business goals. Additionally, employees receive eight hours of paid volunteer time each year, access to an on-staff health coach and personal trainer, plus many other perks. Delta Dental is an Equal Opportunity Employer.

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