Job Title:

Number of Positions:

Location:

Location Specifics:

Job Summary:

Must reside in Metropolitan Davidson County, Tennessee or a county contiguous to Metropolitan Davidson County, Tennessee. 

Position Description

Plans,organizes, and oversees the administrative and technical functions of theGovernmentPrograms Special Investigation Unit (SIU) teams, including claims, data, research and review, and audits and investigations, to ensure regulatory, contractual, corporate and departmental goals and objectives are met.

Primary Job Responsibilities

• Manages the administrative and technical functions of the Government Programs SIU team, including claims, data research and review, and audits and investigations, to ensure the achievement of corporate strategies, goals, and objectives. 
• Manages and administers all SIU processes, including claims, data research and review, and audits and investigations, for Government Programs business as assigned. 
• Interviews, hires, trains, mentors, evaluates, and develops staff to ensure accountability for the achievement of corporate, departmental, and individual goals and objectives.
• Manages staff involved in data research and review, the development of reports, and acts as a consultant to internal and external customers on reporting, analytics, and research issues.  
• Develops, monitors, and enforces policies, procedures, guidelines, and standards for audits and investigations. Develops and prepares departmental reports and analyzes business processes and information to ensure all applicable regulatory and contractual requirements are met.   
• Aids law enforcement agencies or attorneys in the decision, defense, and prosecution of fraud, waste, and abuse, including responding to subpoenas, preparing documentation, and testifying in administrative or judicial proceeding regarding violations of contracts.  
• Develops and maintains trusted relationships with business partners to provide guidance, assess requirements, and promote the use of services and enterprise solutions where appropriate to achieve business partner goals.   
• Serves as a subject matter expert for data research and review, audit and investigations, and SIU claims processing questions as it relates to provider agreements, DeltaUSA processing policies, client contracts and regulatory compliance for government program contracts. 
• Oversees SIU claims processing; creates, defines, and enforces procedures and processes to ensure claims are processed timely and accurately; ensures new business rules/claim routes are implemented, claim processing guidelines updated, and claims processed appropriately; develops and prepares departmental reports and analyzes business processes and information. 
• Maintains monthly worklist and individual production and quality control across the SIU claims processing team, to ensure internal objectives, performance guarantees, service level agreements, and regulatory compliance are met. 
• Acts as a resource for staff and manages and maintains relationships with internal departments, committees, affiliates, and other various external customers to provide dental expertise and/or interpretation of dental policies, procedure codes and processing guidelines in the areas of SIU claims adjudication, fraud, waste, and abuse activities, including audits and investigations and data research and review.  
• Develops and implements short and long-term departmental strategies, goals, and objectives.
• Develops and monitors the annual departmental budget for the Government Programs SIU team.  
• Manages, measures and evaluates multi-departmental activities to ensure continuous improvement of programs and services.  

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

#LI-Hybrid

Minimum Requirements:

Position requires a bachelor’s degree in statistics, criminal justice, finance, healthcare management or a related field, seven years of experience auditing or analyzing data, or resolving complaints in the insurance industry, and three years of leadership experience. Previous experience using a claims processing software application or analyzing group or provider contracts in the insurance industry is preferred. Will accept any suitable combination of education, training, or experience.

Position requires advanced knowledge of the insurance industry, dental terminology, procedures, and dental insurance products; ability to use data extraction and analytic tools, word processing, spreadsheet, and presentation software skills; strong verbal and written communication skills, strong organizational and analytical skills; the ability to lead multiple teams; the ability to interpret contract language related to fraud, waste, and abuse and claims processing; the ability to manage multiple assignments with competing deadlines; and the ability to resolve complex problems using independent judgment. Experience with SQL and/or ACL preferred. CFE, CIA, AHFI also preferred.