Fraud, Waste, and Abuse (FWA) Auditor/Investigator

POSITION SUMMARY

The Dental Fraud, Waste, and Abuse (FWA) Investigator/Auditor is responsible for conducting retrospective and prospective reviews, investigations, and audits of dental providers to identify potential fraud, waste, abuse, overpayments, and non-compliant billing practices. This position analyzes provider claims and clinical documentation, conducts audits, develops investigative findings, supports recovery efforts, and collaborates with internal and external stakeholders to ensure compliance with applicable regulatory, contractual, and organizational requirements. The Investigator/Auditor assists in protecting plan assets, mitigating compliance risks, and supporting referrals to regulatory and law enforcement agencies when appropriate.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Fraud, Waste, and Abuse (FWA) Investigations and Audits

• Provider Auditing and Investigations

• Receive, assess, document, and manage allegations of fraud, waste, abuse, and other compliance concerns.

• Conduct comprehensive remote and onsite audits of provider claims, dental records, billing documentation, and related supporting materials.

• Analyze audit results to identify improper billing practices, overpayments, coding irregularities, and patterns of non-compliance.

• Prepare detailed audit reports, investigative summaries, workpapers, and supporting documentation.

• Maintain complete and accurate case files and evidence in accordance with legal, regulatory, and organizational requirements.

• Coordinate investigative activities with internal business units, including but not limited to Claims Administration, Provider Relations, Government Programs, Legal Counsel, Dental Consultants, and Executive Leadership.

• Escalate significant compliance and FWA risks to the Compliance and Privacy Officer and senior leadership as appropriate.

• Corrective Actions and Recovery Efforts

• Recommend and monitor corrective actions, including provider education, repayment agreements, claim payment edits, sanctions, and network participation actions.

• Assist in the identification, calculation, recovery, and documentation of overpayments resulting from audit and investigative findings.

• Collaborate with management to develop, implement, and track corrective action plans (CAPs) to address identified deficiencies.

• Data Analytics and Monitoring

• Analyze claims, utilization, and provider billing data to identify emerging risks, outlier activity, aberrant billing patterns, and potential indicators of fraud or abuse.

• Conduct trend analyses and risk assessments to support proactive monitoring and targeted investigations.

• Partner with internal stakeholders to develop data-driven approaches to strengthen FWA detection and prevention efforts.

• Regulatory and Agency Coordination

• Support referrals of suspected fraud cases to appropriate federal, state, and local agencies, including Medicaid, Medicare, law enforcement, and other oversight entities, when warranted.

• Respond to requests for information from regulatory agencies, auditors, and law enforcement organizations.

• Support internal and external audits, investigations, and regulatory examinations.

• Compliance Monitoring and Operational Support

• Assist in ongoing compliance monitoring and auditing activities.

• Prepare timely, accurate, and comprehensive reports, analyses, and workpapers.

• Communicate findings and recommendations to management and monitor remediation efforts to ensure timely resolution.

• Research and monitor changes in applicable laws, regulations, contractual requirements, and industry best practices on FWA and dental provider billing practices.

• Develop, maintain, and enhance FWA-related policies, procedures, workflows, and training materials.

• Prepare ad hoc reports, dashboards, and analytical summaries to support compliance and operational objectives.

• Maintain working knowledge of federal and state healthcare regulations, including Medicaid, Medicare Advantage, and commercial dental program requirements.

Other Duties and Responsibilities:

• Support the Compliance and Privacy Officer with special projects, investigations, and departmental initiatives.
• Prioritize and manage multiple assignments while meeting established deadlines and performance expectations.
• Serve as backup support for designated compliance functions as assigned.
• Participate in compliance training and professional development activities.
• Perform other duties and responsibilities as assigned.
• Other miscellaneous duties and responsibilities as assigned.

MINIMUM QUALIFICATIONS AND EXPERIENCE

To perform this job successfully, the individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, physical demands, and/or ability required to perform the essential duties of this job.

Education

• High School Diploma or its equivalent required.
• Bachelor's degree in business administration or health care related field, or an equivalent combination of education, training or work experience.

Experience

• Three (3) years of experience in healthcare fraud investigation, audit, compliance, healthcare operations, claims analysis, law enforcement, criminal justice, or a related field
• Experience conducting provider audits, investigations, or payment integrity reviews preferred.
• Dental insurance claims processing or dental office operations experience preferred.
• Knowledge of Medicaid, Medicare Advantage, commercial health plans, fraud prevention methodologies, and regulatory requirements preferred.
• Experience using data analysis tools to identify trends, anomalies, and potential fraud indicators preferred.

Licenses/Certification

• Certified Fraud Examiner (CFE), Certified Quality Auditor (CQA), or equivalent auditing licensure preferred.
• Investigations or payment integrity reviews preferred.
• Dental insurance claims processing or dental office operations experience preferred.
• Knowledge of Medicaid, Medicare Advantage, commercial health plans, fraud prevention methodologies, and regulatory requirements preferred.

Skills and Knowledge

• Well-developed understanding of audit techniques and practices.
• Ability to handle confidential and sensitive issues and materials.
• Ability to work well under pressure and meet deadlines.
• Ability to analyze complex topics or issues and recommend alternatives and solutions.
• Ability to handle multiple tasks and pay attention to details.
• Ability to communicate clearly and fluently in writing and orally with all levels of staff and management on sensitive matters.
• Technical knowledge to understand computer applications for problem-solving (prefer Windows, Word, Excel, and PowerPoint).

Note: The above information on this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job. Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodations will be made to enable qualified individuals with disabilities to perform the essential functions of this position.