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Deloitte Program Integrity – Senior Consultant (Dental Claims Investigator) in McLean, Virginia

Are you an analytical,data-driven professional? Are you interested in a role that uses leading edgeanalytics and offers an opportunity to provide front line support to solve our clients most challenging problems associated with health care Payment Integrity /Fraud, Waste and Abuse detection and prevention? If so, the Forensic Analyticspractice is the place for you!

As a data analyst, you will be expected to apply yourspecialized knowledge of data acquisition, management, analysis, andinterpretation directly to dental claims, eligibility, policy, etc., data,providing actionable insights that Deloitte, our clients, decision-makers, andothers can use. It s a great career choice for those who want to applyhealthcare expertise in a novel and innovative way.

ForensicAnalytics is a fast-growth practice within Deloitte Risk and Financial Advisorythat centers around several of the hottest areas of business today analytics,forensic analysis, and litigation support and the specialized skills thatmake careers in these areas both fascinating and in high-demand. Our Analyticsteam makes extensive use of data, statistical and quantitative analysis,rules-based methods, and explanatory and predictive modeling to bring insightsto client issues. Our work increasingly employs specialized competencies, suchas advanced analytics, visualization, and geospatial techniques.

Work you ll do

  • Provide domain experience in review of dental plan policy

  • Guide the development and review of new dental rules

  • Maintain a deep, working understanding of ADA dental procedures codes and standard dental claim processing policies as defined by our dental client

  • Conducting investigations into dental cases to identify potential fraud, waste, abuse, and improper payments.

  • Performing and interpreting dental billing patterns to identify potential fraud, waste, abuse, and improper payments.

-{PS..0}->Responsible for the analysis of provider and member claims data,and non-clinical review of dental records pertaining to claims audits andfraud, waste and abuse investigations.

-{PS..1}->Assignments are generally of low to moderate complexity andfocused primarily on documentation supporting code billed and documentationrequirements, but may also involve other areas such as:

o -{PS..2}->compliancewith applicable laws and regulations,

o -{PS..3}->regulatory reporting requirements

-{PS..4}->Conductinvestigations into dental cases to identify potential fraud, waste, abuse, andimproper payments.

  • Perform and interpret provider billing patterns to identify potential fraud, waste, abuse, and improper payments.

  • Conduct background research on provider and associated partners.

  • Collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.

  • Analyze information submitted on the dental claims to determine amount and nature of billable services.

  • Identify trends and possible concerns related to potential inappropriate submission of claims by providers or facilities.

  • Review and analyze claims and dental charts submitted by the provider or facility to determine appropriateness of billing and documentation.

  • Document findings for each claim line with appropriate claims payment calculation in a findings spreadsheet.

  • Summarize findings in a written report which will be provided to management, Plan, and in certain circumstances court proceedings.

  • Interpret provider policy to validate appropriate payment was made.

  • Prepare and present complex written and verbal materials (reports, findings and presentations).

  • Conduct interviews with dental providers to validate services rendered.

  • Contribute to a strong client relationship through interactions with client personnel on investigation-related issues.

  • Contribute to new business proposals and client pursuits.

  • Manage own personal and professional development; seek opportunities for professional growth and expansion of consulting skills and experience.

  • Network and negotiate to identify and sell potential new services or expand existing engagements by leveraging client relationships.

  • Generate marketplace eminence through the creation of intellectual property across a host of mediums including but not limited to: articles, whitepapers, webcasts and other audio-visual presentations.

  • Work under supervision of the Claims Integrity, Manager with moderate latitude for initiative and independent judgment.

The team

Asa member of ourForensicAnalytics practice in the Senior Consultant role, youwillwork on projects that will allow you to collaborate with clients, and other analystsand investigators. As part of these projects, you ll be provided theopportunity to demonstrate your technical, project management and leadershipskills in an environment that provides for outstanding growth and advancement. Positionmay necessitate intermittent travel and requires flexibility with the clientservice projects.


  • Bachelor s degree in Healthcare, Business, Computer Science, Mathematics a related field or equivalent experience.

  • 2 years of Dental Forensic, Investigative, and/or Discovery industry related experience

  • 2 years in a technical or functional role

  • Dental records review and claims analysis experience.

  • Strong analytical & investigative skills.

  • Ability to comprehend dental policy and criteria to clearly articulate health information.

  • Experience with all dental coding (CDT, CPT, HCPCS, DRG, ICD-10, & Revenue Codes).

  • Excellent oral and written communication skills and an ability to communicate effectively with all levels of the organization.

  • Intuitive nature to identify investigational leads regarding fraud, waste or abuse.

  • Ability to work independently and as part of a productive team.

  • Ability to handle multiple and conflicting priorities.

  • Working knowledge of dental review and dental chart audits.

  • Proficient in Microsoft products, specifically Excel.

  • Proven leadership skills demonstrating strong judgment, problem-solving, and decision-making abilities.

-{PS..5}->Pre-sales,proposal, and RFP experience.

  • Experience reviewing dental claims, charts, and x-rays.

  • Experience reviewing and interpreting dental policy.

  • Extensive knowledge of dental procedure codes, dental claims processing, and provider relations, as well as the ability to understand the cascading impact of claims processing policy changes on key performance indicators, claim costs, and overall financial health of the organization.

-{PS..6}->Must be legally authorized to workin the United States without the need for employer sponsorship, now or at anytime in the future.


  • Certified Fraud Examiner is a plus but not required

  • Certified Professional Coder (CPC) or equivalent a plus


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