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SalaryYou are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.
Job Description:
**Must be located in Oklahoma.**
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 Lead Investigator is responsible for the oversight of multiple clients and the assigned investigative team for these markets. Responsible to assure the assigned investigative team conducts comprehensive data analysis and appropriately identifies provider’s s whose utilization patterns are outside of the expected norm from their peers. The Lead Investigator will be responsible to assure all investigative cases are accurate, comprehensive and defensible in all assigned markets. The Lead Investigator will be responsible to assure that all investigators’ case files are complete and accurate following department guidelines. Will participate in any negotiations in assigned markets. Assure that all assigned team investigators are meeting contractual obligations and client expectations in assigned markets. Responsible for working with clients, state agencies and law enforcement related to their investigations as applicable.
How you will contribute:
- Lead Investigator will be responsible for all new business implementations for assigned markets.
- Lead Investigator will be responsible for all aspects of training and onboarding of new Investigators.
- Lead Investigator will be responsible to have a thorough working knowledge of all contracts, client requirements and plan benefits for all assigned markets.
- Lead Investigator will be responsible for all aspects of investigator training as contractual obligations and client requirements are changed and/or updated.
- Responsible for independent interpretation of utilization reports to detect patterns and potential areas of fraud, waste or abuse
- Responsible to query data to conduct comprehensive drill down data analysis to detect patterns and trends of under and over utilization.
- Responsible for the investigation of provider and member fraud and abuse inassigned markets.
- Responsible to 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.
- Responsible for assuring all audit decisions are in compliance with State Medicaid Guidelines, DentaQuest
- Office Reference Manual and plan benefit limitations.
- Responsible for the implementation and updating of all client processes related to Fraud, Waste and Abuse.
- Responsible for the professional relationship with assigned client contacts related to fraud, waste and abuse investigation.
- Responsible for all client facing meetings related to fraud, waste and abuse.
- Responsible for tracking all investigative cases in accurate timeline format in internal fraud tracking database.
- Responsible for managing multiple clients and associated provider networks related to fraud, waste and abuse investigation.
- 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 investigation and client related communications to providers for provision of investigative facts and findings.
- Responsible for all assigned client contractual reporting requirements related to investigative activity and outcomes.
- Responsible for professional relationships with market assigned, state Medicaid agencies, and state and federal law enforcement agencies.
- Responsible for assisting and working in cooperation with market assigned clients and state and federal governmental agencies in the investigation of fraud, waste and abuse.
- Required to participate in all client required trainings related to Fraud, Waste and Abuse.
- Responsible for the preparation and presentation of Utilization Review investigative cases for internal and external Peer Review Committees.
- Responsible for the reporting of all credible allegations of fraud to the assigned designated client contact in a timely manner meeting all contractual requirements.
- Responsible to coordinate and consult with the assigned DentaQuest legal counsel when appropriate.
- Represent DentaQuest in a professional manner at all times.
- Responsible thru data analysis to identify areas for cost containment and application of new processing policies or application of processing policies. Evaluate effectiveness of processing policies to assure accurate and appropriate application.
- Develop new techniques to be used in detecting possible fraud.
- Assist in the development of new reports and provide technical support for implementation of reports or software development.
- Other duties as assigned.
What you will bring with you:
- 5 + years of experience in the Investigation of Fraud, Waste or Abuse, applicable experience in Dental Fraud preferred.
- 7 + years of experience in clinical dentistry or related business experience. College degree is preferred.
- Knowledge of general computer software (Excel, Word, Outlook, Adobe). Typing skills of 40+ words per minute.
- 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.
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 www.sunlife.com/us 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.
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Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email recruitingUS@sunlife.com to request an accommodation.
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 California Privacy Policy and Notice.
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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.
