Dental Director - Fraud and Waste
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AI Summary
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The Dental Director relies on dental background and reviews dental claims. The Dental Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.The Dental Director provides dental interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
Complete all clinical reviews associated with dental fraud, waste and abuse investigations and create a recommendation on the case direction.
Stay up to date on all dental industry standards and provide education and guidance to creating new data tools to review provider outliers
Coordinates investigation with law enforcement authorities as well as assembles evidence and documentation to support successful adjudication, where appropriate.
Conducts on-site audits of provider records ensuring appropriateness of billing practices.
Prepares complex investigative and audit reports and advises executives to develop functional strategies for dental fraud, waste and abuse case on matters of significance.
Use your skills to make an impact
WORK STYLE: Remote/work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week-- some flexibility might be possible, depending on business needs.
Very minimal travel might be required for trainings, meetings, and/or conferences (less than 5% travel).
What you need for success! - Required Qualifications
Doctor of Dental Surgery (DDS) degree or DMD
A minimum of five years of experience in a clinical dentist office as a practicing dentist
Must hold a clear and active license to practice dentistry (in any US state)
Must be comfortable with data analysis/report interpretation
Strong computer skills including MS Office desktop applications (Word, Excel, PowerPoint, Visio, Project)
Demonstrated competency in written communication skills
Solid understanding of process / workflow concepts
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab
The Dental Director conducts clinical reviews of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews and/or condition committees.
Preferred Qualifications
5+ years of investigative or auditing experience of dental related claims
Knowledge of Medicare regulations
Knowledge of Medicaid regulations
Knowledge of Commercial insurance regulations
Additional Information - How We Value You
Benefits starting day 1 of employment
Competitive 401k match
Generous Paid Time Off accrual
Tuition Reimbursement
Parental Leave
Work at Home Requirements
WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Interview Format
As part of our hiring process, we will be using on-demand technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making through on-demand candidate assessments.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in an on-demand assessment with pre-determined questions. You should anticipate the assessment to take approximately 10-15 minutes.
Your on-demand assessment will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
SSN Task via Workday
Should you be extended a formal employment offer you will receive a request to enter your SSN into our Workday system to scan for duplicate profiles.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 10-12-2026
About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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