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Job Summary:

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:

Plans, organizes, and supervises the Provider Auditor Focused Review Special Investigation Unit (SIU) , including oversight of data research and review, and audit and investigation activities. E nsures all team operations align with corporate and departmental goals and objectives, maintains compliance with applicable standards and policies, and supports continuous improvement in Focused Review processes.

Primary Job Responsibilities:

• Supervises and monitors the daily administrative and technical functions of the Focused Review SIU teams, data research and review, and audit and investigation activities to ensure efficient, compliant operations that support departmental and corporate goals and objectives.
• Supports staff recruitment, onboarding, and development by assisting with interviewing, training, mentoring, and evaluating team members to promote accountability and achievement of individual and team objectives.
• Oversees staff engaged in data research, report development, and analytics, serving as a resource for audit and research questions and providing guidance to internal and external stakeholders on reporting issues, provider agreements, processing policies, client contracts, and regulatory compliance for both commercial and government programs.
• Implements and enforces policies, procedures, and standards for audits and investigations, and assists in preparing departmental reports and analyzing business processes to ensure compliance with regulatory requirements for both commercial and government programs.
• Facilitates communication with law enforcement and legal representatives by supporting the preparation of documentation and responses to subpoenas, and assisting with administrative or judicial proceedings related to fraud, waste, and abuse.
• Builds and maintains collaborative relationships with business partners to provide operational support, clarify requirements, and promote effective use of SIU services and solutions.
• Acts as a liaison for staff and internal departments, providing expertise and interpretation of dental policies, procedure codes, and processing guidelines related to claims adjudication, fraud, waste, and abuse activities.
• Assists in developing and implementing departmental strategies, goals, and objectives to support continuous improvement and operational excellence.
• Supports budget monitoring and resource allocation for the Focused Review SIU teams as directed by management.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Hybrid

Minimum Requirements:

Position requires a bachelor’s degree in business administration , criminal justice, or related field a nd five years of experience conducting investigations, audit s, or complex data analy sis within the insurance industry. Previous leadership experience is preferred , as well as experience reviewing claims activity, provider behavior, or group contract compliance. Will accept any suitable combination of education, training, or experience.

Position requires advanced knowledge of the insurance industry operations; strong investigative skills related to fraud, waste, and abuse; proficiency with analytic al tools, word processing, spreadsheet, and presentation software skills; strong verbal and written communication skills, strong organizational and analytical skills; the ability to lead investigative teams ; the ability to interpret contract language and identify indicators of fraudulent activity ; the ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment. Professional certifications such as CFE, CIA, AHFI are 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.