About the role
Headquarters: U.S. Employees (Remote)
URL: http://sunlife.com
Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.
Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.
DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.
Job Description:
Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK.
** Candidate must reside in the state of Iowa.
The Opportunity:
The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse. The Clinical Investigator will conduct in-depth analysis, peer analysis trend analysis and statistical analysis to identify providers whose utilization patterns are outside of the expected norm from their peers in their assigned markets. They will have full responsibility for all contractual obligations for their assigned clients related to fraud, waste or abuse. The Clinical Investigator is responsible for the professional relationship with assigned clients related to fraud, waste and abuse and is responsible for all aspects of the investigative process from identification, initiation, completion and referral of the investigation as applicable. The Clinical Investigator is responsible for working with providers to educate, impose corrective action and to reach case resolution. The Investigator works closely with clients, managed care organizations, state agencies and law enforcement related to their investigations as required.
How you will contribute:
Responsible for clinical interpretation of dental radiographs.
Independently interpret utilization reports to detect patterns and potential areas of fraud, waste or abuse.
Query data to conduct comprehensive drill down data analysis to detect patterns and trends of under and over utilization.
Investigate provider and member fraud and abuse in assigned markets.
Manage multiple clients and associated provider networks related to fraud, waste and abuse investigation.
Work with and in consultation with DentaQuest Dental Directors during the investigative process to assure accurate and defensible clinical decisions.
Responsible for the accuracy of all investigative decisions and that the decisions are clinically sound, supported by appropriate and documented authority and defensible.
Assure all audit decisions are in compliance with Medicare regulations, State Medicaid Guidelines, DentaQuest Office Reference Manual and plan benefit limitations.
Assist management in overpayment negotiations with providers related to the results and findings of an investigation.
Responsible for the implementation and updating of all client processes related to Fraud, Waste and Abuse.
Maintain the professional relationship with assigned client contacts related to fraud, waste and abuse investigation.
Responsible for all investigation and client related communications to providers for provision of investigative facts and findings.
Responsible for all client facing meetings related to fraud, waste and abuse.
Track all investigative cases in accurate timeline format in internal fraud tracking database.
Have the ability to independently manage workflow to meet business needs, assure contractual obligations for all clients are met and to meet departmental metrics.
Responsible for the development of interdepartmental relationships to assure all issues related to fraud, waste or abuse are identified and appropriately investigated.
Responsible for the preparation and accuracy of recovery documents for processing and assure that they are completed correctly and in a timely fashion.
Responsible for all assigned client contractual reporting requirements related to investigative activity and outcomes.
Maintain professional relationships with market assigned, state Medicaid agencies, and state and federal law enforcement agencies.
Assist in the ongoing evaluation of departmental policies and procedures.
What you will bring with you:
Licensed Registered Dental Hygienist is preferred.
3 + years clinical experience and/or related investigative business experience.
Experience in Dental Utilization Management or Review, preferred
Preferred skills
Knowledge of general computer software (Excel, Word, Outlook, Adobe).
Clinical experience and knowledge of dental procedures and terminology is required.
Effective oral communication and business writing skills are required.
Attention to detail, accuracy and organizational skills are essential.
Effective interpersonal skills are essential.
Ability to prioritize and adapt to changing priorities is essential.
Salary:
Salary Range: $54,100 - $81,200
At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.
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We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.
Life is brighter when you work at Sun Life
At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We’re proud to be recognized in our communities as a top employer. Proudly Great Place to Work® Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities.
We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [email protected] to request an accommodation.
For applicants residing in California, please read our employee California Privacy Policy and Notice.
We do not require or administer lie detector tests as a condition of employment or continued employment.
Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Job Category:
Claims - Health & Dental
Posting End Date:
30/07/2026
To apply: https://weworkremotely.com/remote-jobs/sun-life-iowa-clinical-investigator-consultant-must-reside-in-iowa-1