Dental Fraud, Waste, and Abuse (FWA) Coordinator at Delta Dental of Arkansas

Sherwood, Arkansas, United States -

Full Time

Start Date

Immediate

Expiry Date

22 Jun, 26

Salary

0.0

Posted On

24 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Data Mining, Analytics, Fraud Detection, Claims Analysis, Compliance, Investigation, Pattern Recognition, SQL, SAS, Excel, Tableau, CDT Coding, Dental Billing, Utilization Management, Process Improvement, Regulatory Compliance

Industry

Insurance

Description

Dental Fraud, Waste, and Abuse (FWA) Coordinator Job Summary: The Dental Fraud, Waste, and Abuse (FWA) Coordinator is responsible for supporting the identification, prevention, and resolution of fraud, waste, and abuse within the organization’s commercial dental plan operations. This role combines investigative, analytical, and compliance functions with a strong focus on data mining and pattern recognition to detect improper billing, coding, and utilization practices. The FWA Coordinator plays a key role in maintaining program integrity, ensuring regulatory compliance, and protecting plan assets. The FWA Coordinator implements priorities and methodologies defined by the Director of Provider Services and Utilization Management and ensures operational alignment with clinical policies established by the Dental Director. The coordinator will monitor operational effectiveness and drive continuous process improvements to support efficiency, compliance, and provider experience. Primary Job Responsibilities: * Utilize data mining and analytics tools to monitor claims data for aberrant patterns, overutilization, and potential fraud indicators specific to commercial dental plans. * Investigate suspicious claims and provider activity through thorough chart reviews, data trend analysis, and internal/external research. * Collaborate with IT, data analytics, and clinical teams to refine queries, build reports, and improve fraud detection algorithms. * Prepare detailed investigative reports and summaries to support internal decision-making and potential enforcement actions. * Coordinate with internal departments, including Claims, Legal, Network Management, and Provider Services, to facilitate timely resolution of FWA issues. * Assist in development and delivery of provider education initiatives to promote compliant billing practices and reduce unintentional errors. * Track and maintain documentation of all FWA cases and associated actions in accordance with regulatory and organizational requirements. * Monitor industry trends, regulatory updates, and best practices in dental FWA prevention and detection, especially as they pertain to commercial dental benefits. Minimum Qualifications: * Bachelor’s degree in Healthcare Administration, Public Health, Data Analytics, or a related field required. Equivalent experience may be considered. * 2–5 years of experience in fraud detection, dental claims analysis, or healthcare compliance within a commercial dental or medical plan. * Experience using data mining tools (e.g., SQL, SAS, Excel, Tableau, or similar platforms) to detect and investigate patterns of concern. * Familiarity with commercial dental insurance operations and claim workflows. * Strong working knowledge of CDT coding, dental billing standards, and provider reimbursement methodologies. * Demonstrated ability to analyze large data sets to identify trends and anomalies. * Excellent written and verbal communication skills, including ability to prepare concise reports and deliver findings to cross-functional teams. * High level of discretion when handling sensitive and confidential information. * Ability to work independently and manage multiple projects simultaneously. Preferred Qualifications: * Certified Fraud Examiner (CFE) * Certified Dental Coder (CDC) * 2–5 years of experience in fraud detection, dental claims analysis, or healthcare compliance within a commercial dental or medical plan. * Advanced training or certification in data analytics or health informatics * Experience as a registered dental hygienist or other dental clinical experience. * Advanced knowledge of dental terminology and procedure codes. * Fraud detection and deterrence experience or credentials. * Experience in program integrity or compliance roles.

Responsibilities

This role supports the identification, prevention, and resolution of fraud, waste, and abuse within commercial dental plan operations by utilizing data mining and analytical tools to monitor claims data for aberrant patterns. Responsibilities also include investigating suspicious activity, preparing detailed reports, and coordinating resolutions with various internal departments.