Consultant

• 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 and that the decisions are clinically sound, supported by appropriate and documented authority and defensible
• Assure all audit decisions are in compliance with Medicare regulations, State Medicaid Guidelines, DentaQuest Office Reference Manual and plan benefit limitations
• Assist management in Responsible for overpayment negotiations with providers related to the results and findings of an investigation
• Responsible for the implementation and updating of all client processes related to Fraud, Waste and Abuse
• Maintain the professional relationship with assigned client contacts related to fraud, waste and abuse investigation
• Responsible for all investigation and client related communications to providers for provision of investigative facts and findings
• Responsible for all client facing meetings related to fraud, waste and abuse
• Track all 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 all clients are met and to meet departmental metrics
• Responsible for the development of interdepartmental relationships to assure all issues related 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 all assigned client contractual reporting requirements related to investigative activity and outcomes
• Maintain professional relationships with market assigned, state Medicaid agencies, and state and federal law enforcement agencies
• Assist in the ongoing evaluation of departmental policies and procedures

Clinical Investigator Consultant

Data Consultant

Senior Project Consultant

General Liability Claims Consultant

Senior Underwriter Consultant

Senior Mining Consultant