Iowa Clinical Investigator Consultant - Must Reside in Iowa

Role Overview

The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste, or abuse (FWA). The role focuses on detecting utilization patterns that fall outside expected norms compared to provider peers in assigned markets.

Responsibilities

• Conduct in-depth and statistical claims analysis to identify potential FWA cases.
• Perform clinical interpretation of dental radiographs.
• Independently interpret utilization reports and query data for drill-down analysis (under-/over-utilization patterns).
• Investigate provider (and member) fraud and abuse in assigned markets.
• Manage multiple clients and associated provider networks tied to FWA investigations.
• Coordinate with DentaQuest Dental Directors to ensure accurate and defensible clinical decisions.
• Ensure investigation decisions are clinically sound, documented, and supported by authority.
• Maintain FWA-compliant audit decisions in line with Medicare, State Medicaid guidelines, and internal manuals/plan benefit limitations.
• Support provider education, corrective action, and case resolution.
• Assist management in overpayment negotiations with providers based on findings.
• Implement and update client FWA processes.
• Manage professional relationships and lead client/provider communications and client-facing meetings.
• Track investigation cases in internal fraud tracking databases with accurate timelines.

Requirements

• Must reside in Iowa.

Nice-to-haves

• Experience with clinical interpretation related to dental radiographs and claims-based investigations.
• Familiarity with Medicare/Medicaid audit and compliance processes for FWA.