Headquarters: U.S. Employees (Remote)
URL: http://sunlife.com

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, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and operate nationwide.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Job Description:

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK.

Candidate must reside in the state of Iowa.

The Opportunity:

The Clinical Investigator is responsible for the retrospective review of paid claims and analysis of claims data to identify provider fraud, waste or abuse. They will conduct in-depth analysis, peer analysis, trend analysis and statistical analysis to identify providers whose utilization patterns are outside the expected norm in their assigned markets. The role involves working with providers to educate, impose corrective action, and reach resolution. The Investigator collaborates with clients, managed care organizations, state agencies and law enforcement as required.

How you will contribute:

• Responsible for clinical interpretation of dental radiographs.
• Independently interpret utilization reports to detect patterns and potential areas of fraud, waste or abuse.
• Query data to conduct comprehensive drill down analysis to detect patterns and trends of under and over utilization.
• Investigate provider and member fraud and abuse in assigned markets.
• Manage multiple clients and associated provider networks related to fraud, waste and abuse investigation.
• Consult with DentaQuest Dental Directors to ensure accurate and defensible clinical decisions.
• Ensure all investigative decisions are clinically sound and supported by documented authority.
• Comply with Medicare regulations, State Medicaid Guidelines, DentaQuest Office Reference Manual and plan benefit limitations.
• Assist in overpayment negotiations with providers based on investigation findings.
• Implement and update client processes related to Fraud, Waste and Abuse.
• Maintain professional relationships with assigned client contacts.
• Communicate investigative facts and findings to providers.
• Attend client-facing meetings related to fraud, waste and abuse.
• Track all investigative cases in an internal fraud tracking database.
• Manage workflow independently to meet business needs and contractual obligations.
• Develop interdepartmental relationships to identify and investigate issues related to fraud, waste or abuse.
• Prepare accurate recovery documents for processing.
• Meet client contractual reporting requirements.
• Maintain professional relationships with state Medicaid agencies and law enforcement.
• Assist in evaluating departmental policies and procedures.

What you will bring with you:

• Preferred: Licensed Registered Dental Hygienist.
• 3+ years of clinical experience and/or related investigative business experience.
• Experience in Dental Utilization Management or Review is preferred.

Preferred skills

• Knowledge of general computer software (Excel, Word, Outlook, Adobe).
• Clinical experience and knowledge of dental procedures and terminology.
• Effective oral communication and business writing skills.
• Attention to detail, accuracy and organizational skills.
• Effective interpersonal skills.
• Ability to prioritize and adapt to changing priorities.

Salary:

Salary Range: $54,100 - $81,200

At our company, we are committed to pay transparency and equity. Salary is competitive nationwide and determined based on your skills, qualifications, experience, education, and geographic location. In addition, this position is eligible for a discretionary annual incentive award.

To apply, visit our application page.

Job Category: Claims - Health & Dental

Posting End Date: 26/03/2026

To apply: Apply here

We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We encourage applications from qualified individuals from all backgrounds.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans. Please email thebrightside@sunlife.com to request an accommodation.

For applicants residing in California, please read our California Privacy Policy and Notice.

We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants in a manner consistent with applicable state and local laws.

Source weworkremotely

Published 2026-02-19 22:42:09