Experience

Integrity Management Services, Inc.

• United States
• Business Consulting and Services
• 1 - 100 Employee

• Medicare/Medicaid Fraud Analyst

  • Nov 2015 - Present

  • Investigate fraudulent activities within a customer's account and prevent future suspicious transactions from occurring by communicating with all stakeholders involved • Conduct investigations on suspicious billing, identify doubtful recipients, and proven non-homebound beneficiaries • Significant contributor to the recovery of $3M+ Medicare payments, deliver presentations to key stakeholders before implementation • Educate, advise, and aid clients on all compliance topics, Medicare, Medicaid, and Health Care Reform • Facilitate random audits and verify providers with a violation of the standard billing and Medicare service standards • Evaluate quality assurance audits on fraud projects before returning to Data Analysts and/or Investigators Show less



Florida Blue

• United States
• Insurance
• 700 & Above Employee

• Provider Solutions Analyst

  • 1998 - 2015

  Provider Solutions Analyst 2008-2015 Accountant, Medicare Reconciliation 2006-2008 Reconciliation/Member Verification 2002-2006 Service/Quality Analyst 1998-2002 • Identified hospital-based billing trends and services and all types of private insurance by performing timely drafting, reviewing, and implementation on matters at hand • Reviewed and validated compliance of complex insurance contracts, policy, various medical plans, and filings • Constantly achieved over 100% production in all areas • Maintained expertise on all guidelines and requirements of agencies that regulate medical/insurance licenses • Established a strong relationship with health plans in addressing credentialing needs, resolve billing, and authorizations • Served as SME for the hospital and provider on all items related to the processing of any/all claims • Assessed complex contracts to ensure terms and conditions, while reviewing claims processing reports • Provided detailed reports to key stakeholders and facilitated weekly meetings on account payments and denial issues • Validated Explanation of Benefits (EOB) dispute, escalate payment variance to NIC management, and generate appeal of unpaid • Delivered support and service to assigned health plans with an emphasis on contract overview and claims resolution • Assessed business performance and suggested actions, elevated project progress, and identified and planed solutions for any problems or issues Show less