Clinical Investigator Consultant, DentaQuest

Job Description

Location : Anywhere in US

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work.

Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America.

The opportunity : The Clinical Investigator Consultant handles the retrospective review of paid claims and evaluation of claims data to identify provider fraud, waste, or abuse.

The Clinical Investigator will conduct in-depth analysis of peers, trends, and statistical data to identify providers whose utilization patterns are outside of the expected norm from their peers in their assigned markets.

They will govern all contractual obligations for their assigned clients related to fraud, waste, or abuse. The Clinical Investigator Consultant owns the professional relationship with assigned clients related to fraud, waste and abuse and handles all aspects of the investigative process from identification, initiation, completion, and referral of the investigation as applicable.

The Clinical Investigator Consultant is accountable for working with providers to educate, impose corrective action and to reach case resolution.

The Investigator works closely with clients, managed care organizations, state agencies and law enforcement related to their investigations as required. How you will contribute :

• Accountable 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 review 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 directors during the investigative process to assure accurate and defensible clinical outcomes.
• Handles the accuracy of all investigative conclusions and that they are clinically sound, maintained by appropriate and documented authority and defensible.
• Assure all audit results are following Medicare regulations, State Medicaid Guidelines, Office Reference Manual, and plan benefit limitations.
• Assist management in overpayment negotiations with providers related to the results and findings of an investigation.
• Accountable 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.
• Manage all investigation and client related communications to providers for provision of investigative facts and findings.
• Govern all client facing meetings related to fraud, waste, and abuse.
• Track all investigative cases in accurate timeline format in internal fraud tracking database.
• Can self-regulate workflow to meet business needs, assure contractual obligations for all clients are met and to meet departmental metrics.
• Administer the development of interdepartmental relationships to assure all issues related to fraud, waste or abuse are identified and appropriately investigated.
• Arrange 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.

What you will bring with you :

• 3 + years clinical experience and / or related investigative business experience.
• Knowledge of general computer software (Excel, Word, Outlook, Adobe).
• Clinical experience and knowledge of dental procedures and terminology is required.
• Experience in Dental Utilization Management or Review.
• 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.
• Licensed Registered Dental Hygienist is preferred.

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms.

If you think you might thrive in this setting, we would love to hear from you.

Not ready to apply yet but want to stay in touch? Join our talent community () to stay connected until the time is right for you!

Life is brighter when you work at Sun Life

• Excellent benefits and wellness programs to support the three pillars of your well-being mental, physical and financial including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more
• Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account
• A flexible work environment with a friendly, caring, collaborative and inclusive culture
• Great Place to Work® Certified in Canada and the U.S.
• Named as a Top 10 employer by the Boston Globe's Top Places to Work two years running

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.

We consider various factors in determining actual pay including your skills, qualifications, and experience. In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives.

More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities.

Join our talented, diverse workforce and launch a rewarding career. Visit us at to learn more. At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work.

Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

For applicants residing in California, please read our employee

Job Category :

Claims - Health & Dental

Posting End Date : 25 / 07 / 2024n

25 / 07 / 2024n