· Research and investigate allegations of fraud, waste and abuse to prevent, detect and deter resulting in maximum plan value (front-end savings, recoveries, projected savings) returned back to plan; using the following tools but not limited to, claims processing systems, medical coverage guidelines, payment policies and member/group benefits and provider contracts.· Utilize data mining techniques, statistical data analysis, and analytical software to identify potential fraud, waste, and abuse against all Programs.· Seek out and develops leads and cases received from sources including fraud alerts, government and private sources.· Develop summary reports that explain key findings in data evaluation.· Develop and implement corrective action plans· Incorporate critical thinking skills and judgment in analysis process to determine best course of action for each tip/case.· Escalate high risk and/or tip & case issues to management· Perform investigations, such desk top and on-site medical record audits, surveillance, undercover work, suspect & witness interview.· Prepare cases for referral to law enforcement officials for prosecution· Testify and give depositions as an expert witness in legal proceedings.· Maintain chain of custody on all documents, documenting all stages of each investigation.· Create, update and follow standard departmental operating procedures, policies, confidentiality and security guidelines.· Develop materials and assist with fraud, waste, and abuse training for internal and external audiences.· Attend seminars / webinars annually to stay current on fraud, waste, and abuse trends and issues.· Participate in corporate task teams as deemed appropriate.

Built and managed a client portfolio, educating clients on life insurance products andcreating customized plans based on individual needs, showcasing strong sales andclient relationship management skills.Developed and implemented strategic sales techniques to meet and exceed salestargets, gaining proficiency in direct sales and customer engagement.Provided thorough product knowledge and personalized service to clients, helping themmake informed decisions while enhancing trust and long-term client relationships.Used CRM tools to track leads, follow up with clients, and optimize customer outreachefforts.Attended regular training sessions to stay informed on life insurance products and bestpractices, demonstrating commitment to continuous improvement in sales.

Conducted thorough field and desk investigations of complex cases, preserving crucial data and evidence for intricate fraud cases, demonstrating expertise in fraud investigations.Mentored new investigators, elevating overall performance and fostering growth, showcasing strong leadership and coaching skills.Utilized extensive searches and surveillance operations to acquire vital evidence, proactively managing risks, displaying excellent investigative techniques.Collected, processed, and analyzed evidence with meticulous attention to detail, ensuring accuracy and chain of custody, utilizing strong analytical skills.Demonstrated sound judgment through thorough analysis of allegations, informing well-founded decisions, displaying critical thinking abilities.Produced comprehensive, well-written reports documenting investigative findings and risk assessments, showcasing strong communication and writing skills.Conducted highly effective interviews with stakeholders, including victims, witnesses, leads, and suspects, exhibiting excellent interpersonal and communication skills.Gathered sworn statements and recorded evidence to reinforce investigative findings while assessing risk factors, displaying attention to detail and evidence handling expertise.Made strategic decisions based on thorough information reviews, balancing risk considerations, utilizing analytical and decision-making skills.

Managed insurance claims, ensuring prompt and satisfactory resolutions for clients, showcasing strong customer service and time management skills.Investigated auto collisions and skillfully determined liability decisions, utilizing analytical and critical thinking abilities, leading to accurate outcomes.Created detailed diagrams of scenes to support liability decisions, providing visual evidence for a comprehensive claims process, demonstrating attention to detail and visual communication skills.Conducted in-depth interviews with insureds, claimants, and witnesses, analyzing police reports, medical documents, and legal records for essential information, exhibiting strong investigative and research skills.Developed and maintained positive customer relations, fostering strong partnerships and ensuring high client satisfaction, showcasing excellent relationship-building skills.Collaborated with team members to handle requests and questions effectively, optimizing customer service, displaying teamwork and communication abilities.Exhibited excellent communication skills through telephone and written interactions, addressing customer inquiries and concerns, demonstrating strong communication abilities.Demonstrated self-motivation and a proactive approach to tasks, contributing to a consistently high standard of work, exhibiting strong initiative and work ethic.

• Gain and apply hands-on experience in conducting fraud investigations under the direction of special agents from the Major Fraud and Drug units.• Analyzed bank records and financial spreadsheets to uncover suspicious purchases, summarizing findings to build money-laundering cases and forwarding findings to agents.• Interviewed numerous victims and evaluated complaints, entering data into division’s database.• Securely packaged, labeled and sorted evidence to maintain chain of custody.• Demonstrated teamwork by working with other special agents when duties under assigned agent were completed.• Participated in large-scale fraud investigations.