Experience

Office of the State Inspector General

• Security and Investigations
• 1 - 100 Employee

• Fraud Investigator/ Regulatory Specialist

  • Sep 2012 - Present

   Receive and analyze referrals and complaints from various sources alleging fraud on the part of a FoodShare, BadgerCare Plus or Wisconsin Medicaid recipient.  Schedule and conduct the interviews with recipient and/ or sources found to be relevant to investigation.  Conduct Surveillance  Collect and review all evidence to determine what violations of program policy, Federal guidelines and/or Wisconsin State Statues have been committed.  Prepare detailed reports documenting investigations to support filing of complaint and other appropriate reports, forms and correspondence  Collect, protect and preserve physical evidence to ensure the integrity of the chain of custody and the admissibility of that evidence in court hearings and trials.  Represent and testify in administrative hearings and other relevant legal proceedings.  Effectively recommend termination, suspension, or other discretionary sanction for fraudulent or abusive recipients based on investigative activities.  Provides technical assistance to county counterparts in strengthening Fraud Prevention and Program Integrity Show less



Hewlett Packard Enterprise

• United States
• IT Services and IT Consulting
• 700 & Above Employee

• Internal Consultant/ Quality Assurance

  • Jul 2010 - Sep 2012

   Responsible for facilitating meetings and workgroups to solve complex Inappropriate and Potential Inappropriate Payment Issues surrounding Wisconsin Medicaid programs  Works with contract compliance management team to assist with identifying, development and monitoring corrective action and creating Corrective Action Plans.  Conducts internal audits of operational and system teams supporting Wisconsin’s ForwardHealth Portal, interChange and other Medicaid Management Information Systems (MMIS)  Lead analyst for Department of Justice and Open Records request submitted through PRISM.  Responsible for preparation of internal audit schedules  Responsible for preparation of final audit reports including observations, recommendation and process improvements  Monitor and investigate Fraud and Abuse complaints submitted by Forward Health Member Service Call Center  Performs weekly internal reviews for Claim Adjudication, and Prior Authorization  Documents and maintains the Team Workgroup Procedures and participates in the development of the common procedures as required.  Provides training on Common and Team Workgroup procedures  Ensures the Wisconsin Healthcare Account QMS is implemented and maintained within the organization, including the documentation and maintenance of the departments’ procedures  Assist operational and systems teams in monitoring the implementation of solutions to any non-conformances and verify the effectiveness of those solutions  Responsible to initiate action to prevent non-conformances in the quality system, process and deliverables. Show less