Job Description:

Program Integrity Analyst
CATEGORY: Clinical Review

REQUISITION NUMBER: PROGR001299


LOCATION: Seattle, WA 98109, USA

Post

Program Integrity Analyst

Job Category: Clinical ReviewRequisition Number: PROGR001299Apply now

Posting Details

• • Posted: October 30, 2024
• Full-Time

• Locations

  Showing 1 location
  Seattle
  400 Fairview Ave N
  Suite 800
  Seattle, WA 98109, USA
  
  Seattle
  400 Fairview Ave N
  Suite 800
  Seattle, WA 98109, USA
  
  Spokane
  611 N. Iron Bridge Way
  Suite 200
  Spokane, WA 99202, USA
  
  Spokane
  611 N. Iron Bridge Way
  Suite 200
  Spokane, WA 99202, USA
  
  Colville
  720 South Washington Street
  
  Colville, WA 99114, USA
  
  Colville
  720 South Washington Street
  
  Colville, WA 99114, USA
  +2 more locationsless locations

Job Details

Description

We are looking for a Program Integrity Analyst to play a big role in safeguarding DDWA purchasers and programs from fraud, abuse, overbilling, misrepresentation, waste and/or violation of contract or law to minimize exposure to financial loss.

This position will also support our Providers by building trust through professional, timely and transparent correspondence, informative outreach and audit follow up, and continual assessment of program thresholds and benchmarks to further improve the provider experience.

At Delta Dental of Washington our vision is that all people can enjoy good oral and overall health, with no one left behind. We succeed because of a shared commitment to a set of values that guide everything we do – for our customers, for our communities, and for each other. We are Accountable. We lean in with Courage. We stay Curious. We are Inclusive. We act with Integrity.

We offer a highly competitive medical, dental and vision plans as well offering a generous 401k match and all employees start accruing vacation and sick time from their very first day. We empower employee development through our tuition reimbursement plan, professional development plans, and employee-led communities.

The pay range for this position In Western Washington varies between $60,435.00 – $84,533.00, and for Eastern Washington varies between $53,720.00 - $75,140.00. Washington Dental Service and its affiliates, including Delta Dental of Washington and Arcora Foundation intends to offer the selected candidate a base pay within this range, dependent on job-related, non-discriminatory factors such as experience. Base pay will also be adjusted based on the candidate's geographic location.

Essential Responsibilities include the following: The list of responsibilities listed is not intended to be comprehensive. Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza reserve the right to change the responsibilities at any time with or without notice.

• Maintains a program that identifies and prevents Fraud, Waste and Abuse.
• Investigate dental office claim/billing procedures, group/ employer, broker and patient activities (including internal fraud investigations) and follows through on all instances where a claim appears to be fraudulently submitted.
• Reviews potential inappropriate actions by providers and/or their staff, including logging, tracking, and ensures that complaints submitted by patients are investigated and resolved within established guidelines, including written correspondence.
• Analyze internal and external data to determine impact to quality of care and risk to the organization to support investigative casework; develop appropriate workplans based on analysis.
• Manages all phases of audits, beginning with research, performing audits and conducting site visits, and final report and recommendation.
• Determine recommendations and prioritize future audits, reverifications, legal cases, and reporting to governmental agencies.
• Assist in developing and facilitating anti-fraud training
• Facilitates the recovery of funds lost as a result of fraud, waste and abuse matters.
• Participates in preparation and response to regulatory audits.
• Engage with providers and their staff to communicate audit findings, provide education on appropriate billing practices, and address any discrepancies; this may include drafting formal letters and conducting discussions to ensure understanding and compliance

Experience, skills, and education do you need to have to succeed in the position: The requirements listed below are representative of the knowledge, skill, and/or ability required to successfully perform the essential functions of the position.

• Bachelor's degree in a related field; or equivalent experience and,
• 3-5 years of experience working with fraud investigation in a healthcare or dental benefit industry. Dental Hygienist experience is a plus.
• Advanced knowledge of dental terminology, dental procedures, and billing codes.
• Strong analytical and problem-solving skills with the ability to interpret data and develop action plans based on findings
• Excellent interpersonal, verbal, and written communication skills
• Ability to work with a broad range of professionals
• Fraud detection and deterrence experience or credentials preferred.
• Valid Washington state driver’s license and insurance required.

Washington Dental Service and its affiliates, including Arcora Foundation, Delta Dental of Washington, and TriForza is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

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