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Work Background
Berkeley Research Group LLCSenior Managing Consultant
Jul. 2018 - Oct. 2024Tampa/St. Petersburg, Florida AreaLed In-Network and Out-of-Network claim disputes, conducting claim adjudication reviews on cases with over 1,700 sample claims with alleged damages ranging from $10 million to $60 million. Managed teams of up to (10) direct reports, interacting with clients and legal counsel on more than (100) cases, and co-led or led over (50) different matters. Co-directed over (20) coding validation reviews, ensuring accuracy and compliance in complex claim adjudication processes. Advised a Monitor appointed by a health plan's delegated entity to develop and perform regulatory compliance audits. This included assessing compliance with claims processing and utilization management authorization requests against regulatory and contractual requirements. Directed engagement teams working with legal counsel on reimbursement disputes for healthcare entities, addressing issues such as DRGs, case rates, stop-loss payments, and service denials. Managed claims disputes involving commercial, Medicare, and Medicaid payments by reviewing deposition testimony, contracts, and discovery documents; assessing damages claims; and re-adjudicating and analyzing "at issue" claims. Supported high-profile investigations by developing algorithms for fraud detection, managing data analysis projects, and identifying fraudulent activities. Delivered actionable insights, enhancing fraud prevention and regulatory compliance. Contributed to refuting fraud allegations, validating payable claims, resolving reimbursement disputes, and offering critical support in multifaceted healthcare litigation. In an advisory role, identified savings and process improvements through data analysis, leading to new policies that boosted efficiency and optimized resource management. Partnered with Medicare Advantage plans to improve Risk Adjustment practices, conducted coding validation, and provided recommendations for regulatory risk mitigation, supporting litigation and compliance through complex analytics.
Berkeley Research Group LLCConsultant
Aug. 2012 - Jul. 2018Tampa/St. Petersburg, Florida Area
OptumInsightSenior Business Analyst
Jun. 2011 - Aug. 2012Tampa, FLSupported development of new edits, designed to stop suspect claims for investigation before they were paid. Identified potential fraud schemes, analyzed claims data to identify volume of claims and potential savings. Created automated reports to track the number of claims and dollars flagged by models and modules throughout the claim systems. Performed ad-hoc analysis for various departments. Studied various data warehouses throughout OptumInsight and UHG and documented them for members of the Advanced Analytics Lab.
Littman JewelersPart-time Sales Associate
Jan. 2009 - Dec. 2011Harrisburg, PAAssisted customers with the selection of in store merchandise and the creation of customized creations.
Created system for merchandise tracking and replenishment for a customizable bracelet line. Aided in routine store upkeep and activities such as: repair intake, special orders, inventory tracking, product staging, customer outreach and special event planning. Awarded employee of the month numerous times.
International Certification and Reciprocity ConsortiumDatabase Administrator
Jan. 2008 - Dec. 2008Provided data consulting in support of business and information technology initiatives to client to improve client database systems
Defined, designed, and built dimensional database to meet customers needs.
Hewlett Packard/ SafeGuard ServicesData Analyst
Oct. 2007 - May. 2011Camp Hill, PARepresented Pennsylvania Medicaid and Medicare Data Analysis Center (PMMDAC) as the Business Objects XI tester. Assisted in the transition from Business Objects 6.5 to XI. Worked with Team members to identify issues and implement solutions. Tested and verified that changes to the database were implemented and working and data was accurate. Fulfilled requests for data that assisted ongoing investigations being conducted by law enforcement agencies, including the Federal Bureau of Investigation, Office of Inspector General, and Pennsylvania Attorney General. Performed data mining and analysis on health care data and applied applicable Medicare and Medicaid policy to identify potential fraud, waste, abuse, and program vulnerabilities. Applied healthcare knowledge and policies to develop programs and data reports that streamlined the process of indentifying fraud schemes and aberrancies in the data. Assembled findings into reports, which were presented to internal investigators, as well as outside agencies. These reports have led to active investigations by law enforcement
Identified Millions of dollars of savings to the Medicare and Medicaid Funds.
Client Solution ArchitectsAssociate Program/Systems Analyst
May. 2006 - Sep. 2007Mechanicsburg, PAProvided documentation support and program management for the DLA IPO RBS Evaluation Designed, developed, and maintained all databases for the DLA Bill Review Contract Conducted data mining, tracked data integrity issues, performed data analysis, and prepared reports as the lead junior analyst on the DLA Bill Review Contract Completed preliminary research and analysis for future contracts and assisted in contract proposals
Uncle Willie's Fireworks IncOwner/Manager
Apr. 2003 - Jul. 2006Selected and purchased products for resale and operations
Chose locations and negotiated rental contracts Sole responsibility for all aspects of employee management
Secured permits and licenses needed to operate
Managed accounting, marketing and business negotiations
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