- Utilize basic data analysis techniques to review information contained in standard claims processing system files (e.g., claims history, provider files) to evaluate provider billing patterns, detect suspicious or questionable billing practices or vulnerabilities, and initiate appropriate action.
- Coordinate program integrity activities and processes including developing and maintaining audit plans and manuals, and coordinating, preparing and performing claims analysis and provider audits.
- Manage all aspects of post-payment reviews and audits, including pulling data from the claims payment system, determining sample size, reviewing data, scheduling meetings to review findings, maintaining appropriate documentation, preparing and presenting reports, and completing any action items.
- Communicate with provider offices regarding questions related to reviews and gathering of additional information (e.g. clinical notes).
- Establish and implement a process for tracking and responding to formal and informal concerns related to potential fraud and abuse raised by internal and external stakeholders.
- Cultivate relationships of trust and respect with management, providers, and other stakeholders.
- Develop and deliver training to promote awareness of fraud, waste and abuse and remediate any training/knowledge gaps.
- Chair internal Program Integrity Subcommittee. Prepare agenda and minutes, schedule meetings, and provide support to questions during meetings.
- Report to management on program integrity activities.
- Perform on-site audits of provider offices, as required.
Experience and qualifications
- Associate or bachelor’s degree in data analysis, statistics, or related field is preferred.
- Experience in the insurance or healthcare industries is helpful.
- Excellent oral, written and verbal skills.
- Computer proficiency with Microsoft office suite, including Word and Excel to prepare reports, memos, summaries and analyses.
- Self-directed, strong ability to work independently with minimal supervision.
- Excellent organization/prioritization skills with proven ability to manage multiple projects and priorities.
- Strong analytical and problem-solving abilities.
Compensation and benefits
Delta Dental provides an excellent compensation and benefit package including medical, dental, vision, life & disability insurance, paid vacation, sick leave, continuing education and 401k. More information about benefits and company culture is available on our Careers page.