Dental Fraud & Abuse Investigator

Lets do great things together!

About Moda
Founded in Oregon in 1955 Moda is proud to be a company of real people committed to quality. Today like then were focused on building a better future for healthcare. That starts by offering outstanding coverage to our members compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Lets be better together.

Position Summary
TheDentalFraud and AbuseInvestigatoris responsible forprovidingaccurateandappropriate documentation research and resolution of written correspondence received from providers and potential Fraud and Abuse investigations under minimal supervision and ensure all resolution letters arein accordance withDelta Dental standards. This is a FT WFH position.

Pay Range
$25.08- $28.21hourly (depending on experience)
**Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page linked below to be considered for this position.

Dental Vision Pharmacy Life & Disability

Required Skills Experience & Education:

1. Bachelors degree or equivalent work experience.
2. 2 years of experience as a Claim Support or Customer Service Representative preferred
3. Typing proficiency of 25 wpm & 10-key proficiency of 105 kspm net on a computer keypad
4. Demonstrated knowledge of dental terminology multiple benefit plans and products.
5. Ability to meet correspondence review timelines.
6. Knowledge and understanding of correspondence and fraud and abuse procedures.
7. Detail oriented and proven initiative analytical and problem-solving abilities.
8. Highly effective organizational skills with the ability to prioritize and meet deadlines.
9. Strong reading verbal written and interpersonal communication skills.
10. Must be able to work independently as well as part of a team dealings with all levels of staff members providers and external customers in a professional manner.
11. Ability to work under pressure and exhibit flexibility in changing priorities.
12. Working knowledge of dental terminology.
13. Proficiency in Moda Health operating systems.
14. Demonstrated proficiency in computer applications such as Word and Excel.
15. Ability to maintain confidentiality and project a professional business image.
16. Ability to communicate positively patiently and courteously.
17. Ability to come into work on time and daily.

Primary Functions:

1. Coordinates interpreting contracts/handbooks and policies and understands overall dental health plan processes.
2. Utilizes guidelines to conduct extensive research and analyzes correspondence and/or fraud and abuse cases pertinent to dental claims to make decisions.
3. Reviews clinical records for completeness and determines if the case is related to an administrative policy or clinical decision. Creates packet for clinical decisions for dental consultants/clinicians to review. Will review all administrative policies to respond directly to those.
4. Independently assesses investigates and resolves difficult issues by utilizing company and industry knowledge of operational areas and all established policies and procedures.
5. Organizes the volume of work and maintains a constant caseload. Monitors day to day compliance of cases to ensure that the various state and federal mandated response time frames are met.
6. Communicates in writing or telephone call with members providers or attorneys regarding claims and policies about Moda Dental Health benefit plans. Requests additional information such as chart notes or other clinical from providers as needed.
7. Accurately enters all correspondence and fraud and abuse cases into the appropriate tacking systems as needed for various reporting and auditing requirements.
8. Consults with management staff on problem cases and interfaces with interdepartmental personnel in resolving provider correspondence and fraud and abuse questions.
9. Responsible for ensuring the correspondence for fraud and abuse cases are completely resolved which may include reaching out to other departments.
10. Prepares all cases upon receipt of the correspondence or fraud and abuse case.
11. Researches and responds to all dental provider correspondence.
12. Performs all primary functions of a dental claims support processor level II which would include adjusting any claims based on outcome of various types of reviews.
13. Other duties as assigned.

Working Conditions &Contact with Others

• Office environment with extensive close PC and keyboard use constant sitting and frequent phone communication. Must be able to navigate multiple computer screens. A reliable high-speed hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek including evenings and occasional weekends to meet business need.

• Internally with dental claims customer service membership accounting and other internal departments. Externally with providers members dental consultants and others.

Together we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race religion color age sex sexual orientation national origin marital status disability veteran status or any other status protected by law. This is applicable to all terms and conditions of employment including recruiting hiring placement promotion termination layoff recall transfer leaves of absences compensation and training.

For more information regarding accommodations please direct your questions to Kristy Nehler or Danielle Baker via our email.