The investigator is responsible for auditing provider and member activities to identify questionable conduct related to claims and contract compliance. They also prepare audit reports, educate stakeholders on contractual requirements, and assist law enforcement in fraud detection and prosecution.
Enters, verifies, and corrects group, member, agent, and eligibility information, and researches rejected or inaccurate records for appropriate updates or claims processing. Prepares group and agent documents, gathers information for reports, maintains departmental records, operates office equipment, and may provide administrative and correspondence support.
The specialist researches, analyzes, and resolves complex dental benefit cases, including compliance issues, appeals, and grievances for government programs. They also coordinate with legal and compliance teams to ensure timely resolution and accurate documentation of claims.
The specialist analyzes and adjudicates dental claims to identify potential fraud or aberrant treatment patterns. They also provide dental expertise and interpretations of policies to internal and external stakeholders.
