As a highly skilled Healthcare Investigator II, and a Military Veteran, I excel in ensuring compliance with healthcare regulations. My career has been marked by successful leadership, the development of efficient processes, and collaboration across departments, always with a focus on enhancing operational excellence.Key Expertise:✔ Facility and Professional Claims (UB-04 / CMS-1500): I swiftly review claims to verify payouts based on CMS and contracting guidelines, ensuring accurate disbursements.✔ Centers for Medicare & Medicaid Services (CMS Guidelines): Skilled in researching and applying CMS rules to confirm compliance for precise payouts.✔ Claim Analysis Based on Provider Contracting: Adept at reviewing provider contracts to increase payment accuracy.✔ Provider Claims Training Facilitation: I've facilitated training for new hires and provided refresher courses for associates on escalated claim issues and adjudication.✔ ICD-9 and ICD-10 Coding: My strong knowledge of CPT codes ensures billing accuracy and payment verification.✔ Medical Fraud, Waste, and Abuse Guidelines: I coordinate across departments to validate proper payments and identify improper billing practices.In my recent role at CarelonRx Pharmacy, I managed customer service operations for 25 associates, improving consumer satisfaction and reducing health risks. As a Customer Service Manager at Elevance Health, I led a team of 17 representatives, coordinated onboarding for new hires, and spearheaded initiatives that significantly reduced network errors.Previously, as an Operations Expert at Anthem, I optimized claim review efficiency and collaborated with the Special Investigations Unit on fraud, waste, and abuse issues. My proven track record includes providing expert guidance to teams and enhancing training processes to ensure operational continuity.I hold a Bachelor of Science (BS) in Networking and Communication Management from DeVry University, graduating magna cum laude. My professional development includes certifications and classes that reflect my commitment to excellence in healthcare operations.