What are the responsibilities and job description for the Investigator - Special Investigations Unit position at Delta Dental of New Jersey?
About Us
Delta Dental of New Jersey and Delta Dental of Connecticut are proud to be leaders in the dental insurance industry, offering a wide range of plans to meet the needs of individuals and employers alike. As New Jersey’s largest dental coverage provider, we are committed to delivering high-quality, cost-effective solutions designed to meet the diverse needs of our customers and our team is growing.
In Connecticut, Delta Dental of Connecticut, Inc. provides fully insured dental coverage, while Delta Dental of New Jersey administers self-funded dental benefit programs. We proudly serve over 1.7 million individuals through more than 1,800 groups, including commercial, school board, and government programs.
Since 1969, Delta Dental has been at the forefront of innovation, offering programs that control costs while ensuring the highest level of benefits.
As a member of the national Delta Dental Plans Association, we provide national dental coverage to over 75 million people across 139,000 groups. Our commitment to excellence is reflected in our prestigious Standard & Poor’s “A ” rating for financial strength. Join us and be a part of a trusted company with a rich history of delivering quality dental benefits to millions.
About the Job
To independently identify, investigate, analyze, and conduct investigations to determine whether health care FWA (fraud, waste, and abuse), overbilling and/or violations of contract or law has occurred, as well as compliance with Delta Dental’s Bylaws, Rules and Regulations, compliance with the Participation Agreement, and adherence to government regulations as required by Delta Dental’s Fraud Prevention and Detection Plan.
This is a full time hybrid position, in office Tuesdays and Wednesdays, and remote Mondays, Thursdays and Fridays. We offer excellent benefits including medical, dental, Rx and vision, 401k , tuition reimbursement, additional ancillary benefits, and ample paid time off.
Essential Functions & Responsibilities
- Identify selection criteria within certain parameters and recommend procedures for office reviews
- Exercise initiative and independent judgement in the investigation of a dental office’s claim/billing procedures, group/employer, broker, and patient activities (including internal fraud investigations), and formulating an action plan to follow through until completed
- Interview patients, dentists, staff, and other professionals, sometimes in confidential settings
- Utilize all available in-house resources as well as non-Delta Dental resources (i.e.- data analysis programs/SAS, computer software programs, files, Business Object reports, websites, etc.) to perform extensive analyses of claims submissions and data collected during audits without the need for direct supervision
- Review, investigate, and follow through on all instances where a claim appears to be fraudulently submitted
- Develop and update memos to provide case histories and perform calculations to determine refunds due to Delta Dental
- Compose detailed correspondence requesting essential information and refunds
- Maintain continuous records of active audits held, and possible future audits for review by the SIU Director
- Collect and correlate data as it pertains to the above and as necessary for legal action as determined by Legal Counsel and/or for reporting to the essential governmental agencies as required by law
- Independently utilize available resources (as mentioned above) to determine recommendations and prioritize future audits, follow-up audits, and legal cases while maintaining the appropriate documentation
- Assist in Anti-Fraud training of in-house associates, business associates, and state and federal individuals, as may be required and/or necessary. This may involve presentations and the preparation of publications and training materials
- Perform other related research and analysis as determined by the department head
- Perform other duties as assigned
Essential Qualifications
DDNJ Competencies
Adaptability/Flexibility | Communication | Computer Skills | Decision Making/Judgment | Dependability |
Initiative | Personal Organization | Problem Solving/Analysis | Productivity | Quality |
Knowledge, Skills & Abilities
Technical and Functional
- Possess a level of competence in claims processing systems
- Proficiency in Microsoft Office Suite
- Ability to analyze data, draw conclusions, be innovative, and detail oriented
- Strong accuracy and mathematical proficiency
- Possess composure and ability to work with professionals including dentists and attorneys in a responsible, confidential, and diplomatic manner
- Excellent oral and written communication skills
- Dental knowledge preferred
Required Physical Abilities
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Ability to sit and perform extensive close keyboard and PC work
- Ability to walk, talk, and hear
- Required to stand and reach with hands and arms
- May occasionally be required to lift items weighing up to 30 pounds
- Ability to drive and a valid driver’s license
Working Environment
- Ability to meet deadlines and attendance standards
- The noise level in the work environment is usually moderate
- This classification will be required to sign a confidentiality agreement
- Occasional visits to dental offices to perform audits
Experience, Education, and Certifications Required
Required Educational Level and Experience Required
- Bachelor’s Degree
- or an Associate Degree plus a minimum of 2 years’ experience with insurance related employment,
- or a minimum of 4 years’ experience with insurance related employment,
- or a minimum of 5 years of law enforcement experience,
- or a minimum of 4 years’ experience working in a dental office in the capacity of a hygienist, assistant, or front desk person,
- or a minimum of 2 years’ experience working in a dental office in the capacity of a hygienist, assistant, or front desk person plus a minimum of 2 years of insurance related employment
Certifications required/preferred
- AHFI a plus
- CFE a plus
- CIFI a plus
- RDH a plus
- RDA or CDA a plus
Approvals
Management retains the discretion to add or change job duties at any time.
