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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in dental utilization management, investigative analysis, and effective communication with providers and clients. Proficient in managing workflows and ensuring compliance with regulatory standards while maintaining strong relationships with stakeholders.
Highest-signal resume keywords
Dental Utilization ManagementInvestigative AnalysisClinical ExperienceEffective Oral CommunicationAttention to Detail
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims Data AnalysisStatistical AnalysisDental Radiograph InterpretationFraud DetectionCorrective Action ImplementationRecovery Document PreparationUtilization Report AnalysisWorkflow ManagementClient CommunicationProvider Education
Soft Skills
Interpersonal SkillsOrganizational SkillsAdaptabilityAttention to DetailBusiness Writing Skills
Tools & Technologies
ExcelWordOutlookAdobeFraud Tracking Database
Certifications & Qualifications
Licensed Registered Dental Hygienist
Industry Keywords
Provider FraudWasteAbuseMedicare RegulationsState Medicaid GuidelinesDentaQuest Office Reference Manual
About the role
Key responsibilities & impact- Conduct retrospective reviews of paid claims and analyze claims data to identify provider fraud, waste, or abuse
- Interpret dental radiographs and utilization reports
- Query data and perform drill-down, peer, trend, and statistical analyses to detect utilization patterns
- Investigate provider and member fraud and abuse in assigned markets
- Manage multiple clients and associated provider networks
- Consult with DentaQuest Dental Directors to support accurate and defensible clinical decisions
- Educate providers, impose corrective action, and reach case resolution
- Collaborate with clients, managed care organizations, state agencies, and law enforcement
- Assist with overpayment negotiations with providers
- Implement and update client Fraud, Waste, and Abuse processes
- Conduct client-facing meetings and communications with providers
- Track investigative cases in the internal fraud tracking database
- Manage workflow to meet business needs, contractual obligations, and departmental metrics
- Prepare accurate recovery documents and client contractual reports
- Maintain relationships with clients, state Medicaid agencies, and state and federal law enforcement agencies
- Assist in evaluating departmental policies and procedures
Requirements
What you’ll need- Must reside in the state of Iowa
- Licensed Registered Dental Hygienist is preferred
- 3+ years clinical experience and/or related investigative business experience
- Experience in Dental Utilization Management or Review is preferred
- Knowledge of general computer software, including Excel, Word, Outlook, and 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
- Effective interpersonal skills
- Ability to prioritize and adapt to changing priorities
- Must comply with applicable Medicare regulations, State Medicaid Guidelines, DentaQuest Office Reference Manual, and plan benefit limitations
Benefits
Comp & perks- Discretionary annual incentive award based on individual and business performance
- Generous vacation and sick time
- Paid family, parental and adoption leave
- Medical coverage
- Company-paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
- Career growth support