Finance, Audit Supervisor

• Jul 2022 - Present

Bureau Director II of the Medicaid Fraud Control Unit

• 2018 - Present

Division Director of the Medicaid Fraud Control Unit

• 2005 - 2018

• Investigation of complaints referred to the MFCU by the Division of Medicaid, Providers, Private Citizens, or other sources. Investigative activities include, but are not limited to field interviews of Medicaid Providers and/or Medicaid Beneficiaries, preparation of report of investigation and submission to administrative superior or other law enforcement agencies. • Assist Special Assistant Attorney Generals in preparing information for litigation or for a criminal proceeding. • Testify in Court / Grand Jury to give evidence of information gathered during the course of investigation. • Work with the Division of Medicaid’s Program Integrity Unit in the detection of suspicious claims submitted by providers enrolled in the Medicaid program, and the referral of these providers to the MFCU. • Track all monies received by the MFCU pursuant to criminal proceedings or pre-filing settlements, and distribute these funds to the Division of Medicaid, Attorney General’s Administration, or as directed by the court or settlement agreement. • Assist in the preparation of MFCU Quarterly and Annual reports that are submitted to the Department of Health and Human Services, Office of Inspector General. • Supervision of three registered nurses, two auditors, and one analyst. Show less

Medicare Hearing Officer

• Oct 2002 - Jun 2005

• Arranged for and held hearings in accordance with the requirements of Title XVIII of the Social Security Act, the regulations promulgated thereunder guidelines issued by the Centers for Medicare and Medicaid Services (CMS) and the internal guidelines formulated by the Medicare Carrier. • Ensured that all hearing decisions comply with applicable Medicare law, regulations and instructions issued by CMS.

Investigator

• Nov 1998 - Oct 2002

• Investigateed complaints received concerning fraudulent activity related to Medicare Claims, and maintained extensive documentation to support case actions. • Continually improved and developed investigative techniques, reviewed claims payment data and statistics in an effort to identify aberrant providers. • Conducted on-site investigations of providers under investigation • Worked with other Benefits Integrity investigators in developing proactive initiatives to identify and deter fraud. • Refered all cases of suspected fraud to the Office of Inspector General of Health and Human Services for criminal investigation and prosecution. • Provided investigative assistance to and network with regional and national Law Enforcement entities. • Worked with Benefits Integrity Unit employees in the preparation of workload and productivity reports. • Provided outreach to Provider and Beneficiary Organizations as requested Network with regional and national Law Enforcement entities.Provide outreach to Provider and Beneficiary Organizations as requested. Show less

Internal Auditor

• Apr 1998 - Nov 1998

• Worked directly with President and CEO in the development of medical compliance guidelines for clients and staff. • Coordinated the development and distribution of marketing materials to potential clients. • Consulted with existing clients to ensure that their records are properly documented to substantiate the type and level of all services billed and are in compliance with government regulations. • Reviewed procedures of internal staff to ensure compliance in billing of Medicare, Medicaid, and private insurance claims. • Worked with internal staff on insurance follow-up and accounts receivable. Show less

Operations Management Analyst Principal

• Aug 1993 - Apr 1998

• Reviewed computer generated data from the Surveillance Utilization Review Subsystem of MMIS to identify billing practices which might be indicative of Medicaid program fraud or abuse. • Evaluated information received from the public regarding possible fraud by providers and/or recipients of the program. • Assigned cases for audit to investigative staff and medical review team. • Provided direct oversight of investigative activities to staff (5 Medicaid Investigators and one Registered Pharmacist), and gave advice as needed by the facts of the case. • Coordinated with the Nurse Supervisor on audit/investigative activities of two Registered Nurses. • Determined final disposition of all assigned cases and their possible referral to the various regulatory agencies. • Identification of potential problems, revisions of current program edits, and review procedures. • Formulated and implemented policy changes based upon audit activity and provider input/ interaction. • Maintained computer data base of all integrity cases for tracking purposes. • Prepared and submitted reports regarding case activities to HCFA on a quarterly basis. • Assumed the duties of the Program Integrity Division Director in his absence. Co-managed the Program Integrity Division from May 17, 1995 – January 31, 1996 • Member of Alabama /Mississippi Medicare Fraud Task Force and Mississippi Health Care Fraud Task Force. Show less

Investigator

• Jun 1985 - Aug 1993

• On-site review and analysis of assigned provider’s medical and/or financial records to ensure compliance with Federal and State Regulations and policies. • Interviewed recipients of medical services at their residences to verify claims submitted by the various providers. • Submitted audit reports to the Medicaid Program Administrator. • Testified in administrative hearings or court as needed. • Assistted the health care provider in receiving correct adjudication of submitted claims. Show less