About the position
At Sun Life, we are dedicated to making life brighter for our clients, and we are looking for a Clinical Investigator to join our team. This position is crucial in ensuring the integrity of our claims process by conducting retrospective reviews of paid claims and analyzing claims data to identify instances of provider fraud, waste, or abuse. The Clinical Investigator will be responsible for performing in-depth analyses, including peer analysis, trend analysis, and statistical analysis, to pinpoint providers whose utilization patterns deviate from the expected norms within their assigned markets. This role encompasses full responsibility for all contractual obligations related to fraud, waste, or abuse for assigned clients, ensuring that we uphold the highest standards of service and compliance. The Clinical Investigator will also maintain professional relationships with assigned clients, guiding them through the investigative process from identification and initiation to completion and referral as necessary. This position requires collaboration with various stakeholders, including providers, managed care organizations, state agencies, and law enforcement, to educate, impose corrective actions, and achieve case resolutions. The ideal candidate will bring a strong clinical background, preferably as a Licensed Registered Dental Hygienist, along with at least three years of clinical experience or related investigative business experience. Experience in Dental Utilization Management or Review is preferred, but we welcome all talented candidates who are eager to contribute to our mission. At Sun Life, we value diversity and encourage individuals from all backgrounds to apply. We believe that a diverse workforce enhances our ability to serve our clients effectively and fosters a culture of innovation and collaboration. If you are looking for a role where you can make a meaningful impact and thrive in a supportive environment, we would love to hear from you.
Responsibilities
- Conduct retrospective reviews of paid claims to identify provider fraud, waste, or abuse.
- Perform in-depth analysis, peer analysis, trend analysis, and statistical analysis of claims data.
- Maintain professional relationships with assigned clients regarding fraud, waste, and abuse.
- Manage all aspects of the investigative process from identification to case resolution.
- Educate providers on compliance and impose corrective actions as necessary.
- Collaborate with managed care organizations, state agencies, and law enforcement during investigations.
Requirements
- Licensed Registered Dental Hygienist preferred.
- 3+ years of clinical experience and/or related investigative business experience.
- Experience in Dental Utilization Management or Review preferred.
Nice-to-haves
- Strong analytical skills and attention to detail.
- Excellent communication and interpersonal skills.
- Ability to work collaboratively in a team environment.
Benefits
- Generous vacation and sick time.
- Market-leading paid family, parental, and adoption leave.
- Partially-paid sabbatical program.
- Medical plans and company-paid life and AD&D insurance.
- Disability programs and more retirement and stock purchase programs.
- 401(k) plan with employer-paid match and employer-funded retirement account.
- Flexible work environment with a collaborative and inclusive culture.
