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Investigator / Customer Service Representative Resume

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Buffalo, NY

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WORK EXPERIENCE:

Confidential, Buffalo, NY

Investigator / Customer Service Representative

Responsibilities:

  • Analyzes data to identify billing inconsistencies, patterns or unusual practices.
  • Understands, interprets and makes investigative determinations concerning CPT, ICD - 10 and
  • Confidential coding as it relates to potential schemes to defraud.
  • Responsible for collecting, researching and validating bills and claims data in order to detect fraudulent, abusive or wasteful activities/practices.
  • Accesses claims information and obtains reports summaries from a variety of perspectives.
  • Prepares audit reports and notification of findings letter suitable for dissemination to provider and counsel.
  • Request records from providers for investigation.
  • Conduct onsite collection of records from providers for audits.
  • Assists in Fraud and Abuse Awareness Training of management and associates.
  • Works with law enforcement (FBI) and health insurance fraud task force to present cases or assist in their investigations.
  • Presents cases to law enforcement (FBI / Task Force) for review to see if they will accept for prosecution.
  • Assists in negotiations with making a provider participating.
  • Assists in setting up policy and procedures for processing of claims.
  • Utilizes Facets and Pega for processing claims.
  • Utilizes Streamline to track member/provider contact and Customized Audit System CAS ( Confidential ) to track allegations and cases.
  • Utilizes Intelligent Investigator (Lexis Nexis) to find behavior regarding fraud, waste and abuse.
  • Documents detailed notes from every customer call to comply with government regulations and auditing.
  • Responds to customer questions regarding their claims in compliance.

Confidential, West Seneca NY

Sr. Data Processing Control Clerk

Responsibilities:

  • Provided district training for proprietary software in person or via Sametime and telephone.
  • Provided telephone support to schools and districts for software applications such as Event
  • Management Registration (EMR) and Textbooks.
  • Manipulated textbook and student data on Excel spreadsheets.
  • Logged problems for software applications such as Textbooks, EMR and Inventory using Bugzilla.
  • Performed quality control of software for fixes and enhancements.
  • Notified districts and employees when fixes and enhancements are in place for software.
  • Tested software such as EMR, Inventory and textbooks before it goes into production.
  • Created detailed user documentation using the appropriate software.
  • Ordered textbooks for private, charter and catholic schools.
  • Organized and prepare materials for user meetings and track workshop attendees using EMR.
  • Distributed current informational material, changes in software or training/workshops for users.

Confidential, Buffalo NY

Technical Support Representative

Responsibilities:

  • Received incoming abuse, security and fraud complaints via Kana email program.
  • Provided escalation point for network operations center queries.
  • Kept Associate Abuse Investigators and Division Complaint Coordinators informed of current vulnerabilities with regard to mass mail, spam, denial of service attacks and hacking.
  • Assisted with handling incoming complaints according to written procedures independently.
  • Assisted in technical support for Abuse Desk tools and applications.
  • Responded to complaints when necessary regarding Confidential specific policy.
  • Monitored and tracked incoming complaints via ESS/Remedy ticketing.
  • Fostered communication between Time Warner Abuse Department and Confidential Divisions.
  • Aided in ensuring Confidential Acceptable Use Policy and Terms of Service are adhered to.
  • Accepted inbound chats from customers regarding high - speed internet.
  • Accepted inbound calls from customers regarding Pivot Wireless Phone service
  • Communicate with customers regarding their internet and Pivot accounts.
  • Troubleshoot connection issues for high-speed internet.
  • Troubleshoot hardware and software issues such as Internet Explorer and Outlook/Outlook Express.
  • Multitask between various technical programs for high-speed internet and Pivot support.
  • Documented each inbound call thoroughly using ESS/Remedy.
  • Educated customers on issues regarding their computer and connection.

Confidential, Buffalo NY

Intern

Responsibilities:

  • Received government clearance for internship.
  • Created graphics using Paint Shop Pro 7.0 for intranet site.
  • Updated Confidential s Office intranet site using Dreamweaver software.
  • Updated the Erie County Cybercrime web page.
  • Assisted employees on Windows programs.
  • Worked in the Automated Litigation Support lab.
  • Assisted Information Technology staff.
  • Assembled computers in the office for the attorneys and staff.

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