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Work Background
Government of Washington DCSr. Investigator
Nov. 2015Washington D.C. Metro Area
UnitedHealth GroupSenior Investigator
Dec. 2012 - Nov. 2015Baltimore, MDResponsible for triaging and analyzing allegations of healthcare fraud, waste or abuse by plan members, medical providers or vendors. Utilizes data from a variety of sources such as claims analysis, information obtained from plan member interviews and document pertinent findings. Performed analytical case oversight reviews of progress of investigation performed by vendors. Processes initial fraud paperwork and enters case creation data and quality check the information entered. Forwards case referrals to the Medicare Drug Integrity Contractor (MEDIC). Utilizes anti-fraud (SIRIS) and law enforcement databases (CLEAR) and determined whether results were pertinent to the investigation.
UnitedHealth GroupInvestigator
Dec. 2012 - Mar. 2015Baltimore, Maryland Area
UnitedHealth GroupInvestigator
Dec. 2012 - Mar. 2015Baltimore, Maryland Area
General Dynamics Information TechnologyFunctional Analyst / Investigator
Feb. 2012 - Nov. 2012Towson, MDConducted data analysis functions to identify subjects of investigation utilizing Excel Pivot tables, developed and investigated cases on suspected fraudulent providers. Performed cursory review of medical records and provided professional opinions on matters of medical necessity. Utilized CLEAR to conduct background searches on subjects of investigation. Examined the use of CPT, ICD-9 and HCPCS coding, conducted interviews with providers and plan members. Proactively developed new leads/cases utilizing a variety of sources.
Magellan HealthInvestigator
Aug. 2011 - Feb. 2012Columbia, MarylandConducted mental health provider fraud investigations, utilized various databases to conduct research, background verifications and aid in investigations. Ensured correct application of the DSM-V and CPT-4 coding in mental health claims. Performed medical chart reviews and made determination to whether the services rendered corroborated with the codes billed by the mental health provider. Developed several case related documents such as maintaining chronologically accurate case notes, developing an investigative plan and at the conclusion of the investigation, writing a case summary detailing all events and actions taken during the course of the investigation.
State of New Jersey JudiciaryJudiciary Clerk III
May. 2007 - Sep. 2011Performed intake functions and troubleshooting duties for the public, entered legal documents into a computerized database for filing, assisted in all aspects of court administrative functions. Performed in person customer service and resolution of inquiries from the public and attorneys and/or paralegals. Demonstrated strong conflict resolution and problem solving abilities with irate litigants and/or attorneys. Displayed empathy and patience in explain court rules and procedures to members of the public.
Health Net of the NortheastInvestigative Analyst
Nov. 2004 - Jun. 2006Received and reviewed all incoming complaints of fraud, maintained fraud financial recovery database, trained new employees to the department, managed a light investigative case load, participated in settlement agreement negotiations. Participated in site audits and physical retrieval of medical records from medical providers’ offices. Maintained case related data in an in-house computerized database. Provided training and guidance to new Fraud Department personnel. Completed requests for investigative assistance (ROI) from a variety of external law enforcement and insurance companies. Assisted in process improvement within the fraud department.
Health Net of the NortheastClaims Analyst
Jan. 2003 - Nov. 2004Developed leadership skills by heading and participating on various employees based committees and interacted with Human Resources personnel in regards to committee matters. Utilized research skills to facilitate inbound inquiries from medical providers, plan members and benefits administrators in regards to inaccurate claims adjudication. Reviewed and interpreted provider service contracts to determine if medical claims were processed accurately and re-adjudicated claims that were found to have been incorrectly processed. Utilized attention to detail in reviewing claims to ensure that all necessary information had been submitted and were coded correctly. Strengthened customer focus skills in providing courteous and friendly resolution to telephonic and written inquiries.
AmeriChoice Health ServicesServices Representative
Dec. 1999 - Mar. 2001Developed experience with working with diverse populations by facilitating the customer service delivery to recipients of state Medicaid benefits. Provided timely, accurate and courteous response to basic and complex inquiries, provided supplemental information to members seeking additional resources not affiliated with the health plan. Provided informal assistance in training new customer services representatives. Received inbound telephone calls from plan members, medical providers in regards to benefits and eligibility and claims status.
Horizon Blue Cross Blue ShieldClient Services Representative
Jul. 1997 - Dec. 1999Provided excellent customer service to written and telephonic requests for information pertaining to benefits and eligibility, claims status and enrollment status. Received and resolved customer service requests to investigate incorrect claim adjudication or claim denials. Assisted plan members in locating and selecting medical providers for treatment. Obtained preliminary clinical information from medical providers seeking prior authorization of services and drafted letters of correspondence to external customers in response to their inquiries or requests.
Prudential HealthcareCustomer Service Representative
Sep. 1996 - Jul. 1997Developed customer service and interpersonal skills by receiving inbound telephone calls in regards to health plan benefits, eligibility, enrollment, and claim status questions. Assisted plan members in making changes in their primary medical care providers, provided follow-up problem resolution to matters that were not resolved during initial contact.
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