Anthem Dental Clinical Fraud Investigator II - Any Anthem Location - 131850 in Denver, Colorado

/ Your Talent. Our Vision. /* At DeCare Dental * , a proud member of the Anthem, Inc. family of companies,* * it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we willdrive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve.


*Location: *Any US. Preferred location in Eagan, MN

Responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. Primary duties may include, but are not limited to:

  • Conducts data mining activities using available tools and internal data warehouse and determining appropriate data reports to investigate aberrant provider activities.

  • Performs comprehensive analysis and clinical evaluation of the collected data.

  • Performs in-depth clinical and data analytics investigations on identified providers as warranted.

  • Examines claims for compliance with relevant billing, clinical, and processing guidelines and to identify opportunities for fraud and abuse prevention and control.

  • Review and conducts analysis of claims and dental/medical records prior to payment.

  • Researches new healthcare related questions as necessary to aid in investigations.

  • Collaborates with other members of the Special Investigation Unit and other internal company areas on matters of mutual concern (medical and dental plans).

  • Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.

  • Coordinates with concerned unit/brand as appropriate regarding approved interventions such as recovery of overpayment, pre-payment audit of claims or putting providers on notice.

  • Works closely with and discusses investigation findings with clinical fraud directors and identified providers.

  • Assists in recovery efforts.

  • Assists with training of new associates.


    Requires a RDH (Registered Dental Hygienist) or similar degree, a minimum of 4 years related experience in the industry investigating suspicious claim activity; or any combination of education and experience, which would provide an equivalent background.

/ Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at // // . EOE. M/F/Disability/Veteran. /

Job Fraud

Title: Dental Clinical Fraud Investigator II - Any Anthem Location - 131850

Location: colorado-Denver

Other Locations: TX-Grand Prairie, IL-Chicago, FL-Plantation, MN-Eagan, NY-Middletown, OH-Cincinnati, NY-Albany, VA-Chesapeake, VA-Charlottesville, IN-Indianapolis, VA-Staunton, GA-Atlanta, NV-Las Vegas, WI-Waukesha, PA-Harrisburg, VA-Richmond, KY-Louisville, GA-Columbus, NY-New York City, ME-South Portland, VA-Vienna, CT-Wallingford, MA-Andover, VA-Lynchburg, VA-Newport News, VA-Harrisonburg, VA-Norfolk, MO-St. Louis

Requisition ID: 131850