Delta Dental of Michigan, Ohio, and Indiana is hiring a Government Programs Appeals and Grievances Research Specialist to direct and assist in the resolution of dental benefit determinations. You will analyze provider and subscriber referrals, review provider billing and treatment records, and support our anti-fraud program. Our All In culture emphasizes taking charge of your career, helping colleagues, and lending a hand in the community.

What You'll Do

Research, analyze, and resolve cases for government programs members involving compliance issues including balance billing, non-delivery of care, quality of care, personality disputes, anti-fraud hotline, internal referrals, and appeals.
Communicate with internal and external customers to obtain necessary information and relay actions taken and the resolution of cases.
Participate in an anti-fraud team responsible for identifying, preventing, and reporting fraud.
Prepare dental claims so appropriate determinations can be finalized with correct procedure policies and bypasses in place, adjudicate claims, analyze documents, maintain claims records, and coordinate adjustments on difficult claims and inquiries.
Thoroughly document case information within a case database for investigation, fraud, and/or legal cases.
Coordinate data to be used by internal or external parties including audits, hearings and for use by legal counsel when necessary. Participate in audits and hearings as necessary, including sample preparation and presentation.

What We're Looking For

Associate's degree in accounting, business administration, criminal justice, dental assisting or hygiene, or a related field.
Four years of experience in a position requiring knowledge of dental terminology, dental procedure codes, or dental office billing and record keeping practices within a provider office, administering dental benefit contracts within the insurance industry, or identifying, analyzing, and resolving compliance issues based on policies and procedures outside of the insurance industry.
Knowledge of word processing, spreadsheet, and database applications.
Strong verbal and written communication skills.
Strong analytical skills.
Ability to work independently and as part of a team.
Ability to manage multiple assignments with competing deadlines.
Ability to identify and resolve problems using independent judgment.

Nice to Have

Previous experience supporting an anti-fraud/abuse program.

Work Mode

This position is based locally in Michigan.

The company will provide equal employment and advancement opportunity without regard to race, color, religion, gender, gender identity, gender expression, age, national origin, familial status, citizenship, genetic information, disability, sex, sexual orientation, marital status, pregnancy, height, weight, military status, or any other status protected under federal, state, or local law or ordinance.