COMPUTER SKILLS:

Microsoft Office Suite (Word, Excel PowerPoint, Outlook) SharePoint, STARS (Sentinel, Informant, Commander), Macintosh, NASCO, SharePoint

RELEVANT EXPERIENCE:

Investigator

Confidential, Washington, DC

Responsibilities:

• Conducts investigations and related actions to prevent, detect and eliminate health care fraud, waste and abuse.
• Conducts preliminary investigation of providers or beneficiaries of health care services and develops recommendations as to the disposition of the case.
• Independently identifies potential causes of risk or that aid in the commission of fraudulent acts and produces protocol and methods to mitigate the risk.
• Analyzes computer generated claims data sets to detect abhorrent billing patterns.
• Prepares preliminary investigations for referral to the Confidential ( Confidential ).
• Remains familiar with District of Columbia rules applicable to the services being examined and any revisions.
• Drafts recommendations of Confidential management for changes in policy and procedures that could be adopted to assist in preserving Medicaid funds from being paid inappropriately.

Provider Fraud Analyst

Confidential, Baltimore, MD

Responsibilities:

• Responsible for identifying and analyzing anomalies that are potentially indicative of improper billing practices or potential fraud, waste or abuse.
• Mining large data sets from a vendor that provides predictive and retroactive analytic services of health care services paid for by the federal government.
• Formulating data requests or inquiries from Medicare and Medicaid databases to elicit specific billing patterns and analyze the results.
• Determining the most effective methods for planning and conducting an investigation and what resources that may be needed.
• Recognizing indicators in the data of particular fraud schemes and working with Assistant US Attorneys or supervisory attorneys to determine applicable administrative, statutory and regulatory law pertaining to the identified potential fraud scheme.
• Gaining and maintaining an understanding of state and federal laws and regulations that govern the investigation and utilizing that understanding to make sound and prudent decisions on the direction and/or scope of the investigation.
• Routinely referenced the Medicare Coverage Database to review Local and/or National Coverage Determinations (NCD/LCD) for specific procedures.
• Compose written summaries on the findings of analysis and making a sound recommendation whether potentially fraudulent billing patterns require further investigation.
• Utilizes various public and subscription based data repositories to gather background data on the subjects of investigation.
• Enters subjects of investigation into anti - fraud information sharing database.
• Identifies and quantifies potential risk to the Medicare program resulting and makes recommendations to mitigate those risks.
• Provides training and development on investigative tools and data manipulation techniques to colleagues and new employees.
• Provides on the job leadership and mentoring to colleagues.

Investigator

Confidential, Baltimore, MD

Responsibilities:

• Received and triaged inbound allegations of fraud, waste or abuse received from member complaint hotline and routed non-fraud related issues to the appropriate area.
• Mined large data sets obtained from self-generated queries of claims database utilizing Microsoft Excel to manipulate data to detect inappropriate billing patterns.
• Analyzed data and drafted written summary of findings to explain whether the subject of the allegation warranted further investigation.
• Routinely referenced the Medicare Coverage Database to review Local and/or National Coverage Determinations (NCD/LCD) for specific procedures.
• Referenced public and subscription based data repositories to obtain data pertaining to the subject and or the investigation.
• Reviewed data analytical reports generated by an external vendor for the purpose of identifying abhorrent providers for investigation.
• Provided training to new employees as to how to review and use the analytical reports.
• Participated in weekly conference calls with the vendor to provide feedback and suggestions to improve the results of the reports.
• Performed telephonic interviews with plan members to obtain information related to the investigation.
• Monitored activity on cases that were referred to an outside investigations vendor to ensure the case was being actively worked and that case updates were made in a timely and accurate manner.
• Entered case information into the Fraud, Waste & Abuse (FWA) Investigations database and referred newly opened cases to the National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC).
• Responded to request for investigational assistance (RFI) from external law enforcement agencies and other insurance carriers.
• Routinely communicated with law enforcement agencies to refer cases, obtain status on previous referrals or to seek permission to take investigative actions on cases that were accepted by the law enforcement agencies.
• Proactively generated new leads/cases from information obtained from hotline complaints or received at anti-fraud information sharing meetings.

Senior Investigator

Confidential, Towson, MD

Responsibilities:

• Participated on an investigations team that was the outsourced vendor to conduct fraud investigations for a smaller health plan.
• Received incoming fraud allegations and conducted preliminary verification on the subject of investigation such as ensuring medical licensure was current, searching for any sanctions or disciplinary actions and ensuring the provider was not excluded from any federally funded insurance plans.
• Utilized STARS-Informant to generate data queries from claims database to assess the level of exposure paid to the subject of investigation and exported query data into Microsoft Excel for analysis.
• Mined large data sets obtained from self-generated queries of claims database utilizing Microsoft Excel to manipulate data to detect inappropriate billing patterns.
• Utilized STARS-Sentinel software to generate provider peer comparison reports to proactively identify providers who were outliers amongst their peers of the same specialty.
• Composed written documents explaining findings of analysis and made recommendations as to whether further investigation was warranted.
• Conducted telephonic and in person interviews as well as office site visits as part of an investigation.
• Collected and performed a non-clinical review of medical records and made observations of deficiencies and proficiencies within the medical chart before the charts were forwarded to clinical staff for a formal medical record review.
• Prepared an audit findings report detailing the findings observed by the investigative and clinical staff, provider educational information as well as any applicable overpayment demand.
• Routinely referenced the Medicare Coverage Database to review Local and/or National Coverage Determinations (NCD/LCD) for specific procedures and included such citations if the LCD/NCD was used as a reason for a denial or down code of a procedure.
• Referred to various public and subscription based databases to obtain investigative information.
• Proactively generated new leads/cases from information obtained from hotline complaints or received at anti-fraud information sharing meetings.

Investigator

Confidential, Columbia, MD

Responsibilities:

• Received and reviewed incoming allegations of fraud perpetrated by mental health providers.
• Referenced health plan holder contracts to determine what Mental Health/Substance Abuse (MHSA) benefit limitations were to aid making valid decision as to whether fraud existed.
• Referenced public license verification databases to ensure subjects of investigation were licensed professionals.
• Routinely referenced DSM-V manual to research mental health diagnosis codes
• Performed audit of patient office notes and reviewed findings with medical director to verify if conclusions were accurate.
• Prepared audit findings/provider education/overpayment demand letters to send to providers.
• Composed case closure summary detailing all actions taken during the course of the investigation.
• Performed peer review of colleagues case closure documents.

Judiciary Clerk

Confidential, Freehold, NJ

Responsibilities:

• Entered a variety of legal filings in a timely and accurate manner into the Judiciary Database.
• Performed intake and customer service functions in the Civil Law Division office.
• Processed requests for wage garnishments and levies on property.
• Operated audio-visual recording equipment during court procedures.
• Maintained written log of activities during court procedures.
• Retrieved pool of potential jurors when a trial commenced and facilitated the voir dire process by logging participants who had been selected and eliminated from jury participation.
• Marked items submitted for evidence during trial and maintained a written list of the items submitted.
• Administered oath once a jury was selected and ensured uninterrupted deliberation.
• Provided training and development to new judiciary clerks.
• Served as a mentor and member of employee satisfaction committee.

Investigative Analyst

Confidential, Matawan, NJ

Responsibilities:

• Served as the subject matter expert for triaging all incoming allegations into the Special Investigations Unit (SIU).
• Routed non-SIU matters to their appropriate department with written memo detailing the nature of the issue.
• Conducted preliminary background investigations on subjects obtaining payment exposure, licensing, tax identification and demographic information.
• Participated in weekly meeting with department manager detailing rationale for initiating an investigation and assigning new cases to department investigators.
• Managed caseload that consisted of non-complex fraud allegations.
• Maintained SIU Financial database recording all identified overpayments and recoveries/retractions.
• Provided training to new department personnel.
• Completed all requests for investigative assistance (ROI)