Iowa Clinical Investigator Consultant
Not Disclosed•Full-TimeHybrid
location_onEast Village, Des Moines, Polk County, Iowa, 50309, United States
About Sun Life U.S. and DentaQuest
Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners, and government programs, we offer a comprehensive portfolio including dental, vision, disability, and healthcare navigation. We operate nationwide with more than 6,400 employees and associates.
DentaQuest, a key part of our ecosystem, manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid, CHIP, Medicare Advantage, and various business sectors. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.
The Opportunity
The Clinical Investigator plays a pivotal role in protecting the integrity of our benefit programs. This position is responsible for the retrospective review of paid claims and the analysis of complex data sets to identify provider fraud, waste, or abuse. You will conduct in-depth, peer, trend, and statistical analyses to pinpoint providers whose utilization patterns deviate from the expected norm within their assigned markets.
Beyond data analysis, you will own the professional relationship with assigned clients regarding fraud, waste, and abuse. Your journey involves managing the full investigative lifecycle—from identification and initiation to completion and referral. You will work closely with providers to educate them, impose corrective actions, and reach case resolutions. This role requires frequent collaboration with clients, managed care organizations, state agencies, and law enforcement to ensure thorough and defensible outcomes.
Work Environment
Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. This role is based in the contiguous United States plus Alaska. Candidates must reside in the state of Iowa.
Our Commitment to Diversity and Inclusion
We are committed to fostering an inclusive environment where all employees feel they belong, are supported, and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives, and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.
Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local laws. We do not require or administer lie detector tests as a condition of employment. We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans.
Life is Brighter at Sun Life
At Sun Life, we prioritize your well-being with a comprehensive benefits package, including generous vacation and sick time, market-leading paid family and parental leave, medical coverage, and a partially paid sabbatical program. We offer a flexible, inclusive, and collaborative work environment that supports career growth. Proudly Great Place to Work® Certified in Canada and the U.S., we have been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.
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Work location
Work model: Hybrid
East Village, Des Moines, Polk County, Iowa, 50309, United States
Des Moines, Iowa
Key Responsibilities
- check_circleInterpret dental radiographs and utilization reports to detect patterns of under or over utilization
- check_circleManage the full investigative process from identification and initiation to completion and referral
- check_circleAssist management in overpayment negotiations with providers based on investigation findings
- check_circleTrack all investigative cases in accurate timeline format within the internal fraud tracking database
- check_circleAssist in the ongoing evaluation of departmental policies and procedures
- check_circleConduct retrospective review of paid claims to identify provider fraud, waste, or abuse
- check_circleDevelop interdepartmental relationships to identify and appropriately investigate fraud, waste, or abuse issues
- check_circleQuery data to perform comprehensive drill-down analysis on provider utilization trends
Requirements
- verifiedLicensed Registered Dental Hygienist preferred
- verified3+ years clinical experience and/or related investigative business experience
- verifiedExperience in Dental Utilization Management or Review preferred
- verifiedKnowledge of dental procedures and terminology required
- verifiedEffective oral communication and business writing skills required
- verifiedMust reside in the state of Iowa
Nice to Have
Licensed Registered Dental Hygienist. Experience in Dental Utilization Management or Review. Knowledge of general computer software (Excel, Word, Outlook, Adobe).
Benefits & Perks
check_circleGenerous vacation and sick timecheck_circleMarket-leading paid family, parental and adoption leavecheck_circleMedical coveragecheck_circleCompany paid life and AD&D insuranceDisability programs
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Frequently asked questions about Iowa Clinical Investigator Consultant at Sun Life
What does a Iowa Clinical Investigator Consultant at Sun Life do?expand_more
In this Iowa Clinical Investigator Consultant at Sun Life role, you will interpret dental radiographs and utilization reports to detect patterns of under or over utilization; manage the full investigative process from identification and initiation to completion and referral; assist management in overpayment negotiations with providers based on investigation findings; and track all investigative cases in accurate timeline format within the internal fraud tracking database.
What are the requirements for this Iowa Clinical Investigator Consultant role?expand_more
To qualify for the Iowa Clinical Investigator Consultant at Sun Life position, applicants should have: Licensed Registered Dental Hygienist preferred; 3+ years clinical experience and/or related investigative business experience; Experience in Dental Utilization Management or Review preferred; Knowledge of dental procedures and terminology required; Effective oral communication and business writing skills required; and Must reside in the state of Iowa.
Where is the Iowa Clinical Investigator Consultant role at Sun Life located?expand_more
Iowa Clinical Investigator Consultant at Sun Life is based in East Village, Des Moines, Polk County, Iowa, 50309, United States. This is a hybrid role.
Is this Iowa Clinical Investigator Consultant job remote, hybrid, or on-site?expand_more
Sun Life has listed this Iowa Clinical Investigator Consultant role as hybrid.
How much experience is required for this Iowa Clinical Investigator Consultant role?expand_more
Iowa Clinical Investigator Consultant at Sun Life typically requires 3+ years of relevant experience at the mid level level.
What skills do you need for the Iowa Clinical Investigator Consultant role at Sun Life?expand_more
Key skills for Iowa Clinical Investigator Consultant at Sun Life include Excel; Word; Outlook; Adobe; Dental Radiographs; Dental Procedures; Dental Terminology; and Medicare Regulations.
What category does the Iowa Clinical Investigator Consultant role belong to?expand_more
Iowa Clinical Investigator Consultant at Sun Life is part of the admin job category on Recrutus.