Damein Moss Email & Phone Number

Clarksville, Tennessee, United States

Concept Research & Development Analyst as part of Optum

Nationwide

Nashville, Tennessee

Determined/implemented appropriate administrative / legal remedies based on the findings of investigative efforts including revocation of billing privileges, suspension of payments, and referral to the OIG, FBI, AUSA or other Federal/ State agency for criminal/ civil proceedings as it relates to Medicare fraud, waste, and abuse. Analyzed medical review determinations, interpreted and analyze data to identify aberrant billing, conducted interviews with Medicare/Medicaid patients, and Medicare/Medicaid providers and staff, and reviewed various govt., legal, and internet research databases to identify possible fraud schemes and corroborate credible allegations of fraud. Corresponded with providers’ attorneys including formal requests and rebuttal responses.Conducted onsite audits; identified and participated in numerous onsite evaluations of Medicare providers. Drafted numerous requests for suspension and/or revocation by the CMS PEOG resulting in suspension of the provider’s billing privileges and reduced loss to the Medicare Trust Fund. Perform desk-level audits of medical documentation for accuracy and proper payment. Identify fraudulent Part A, Part B and DME billing trends.Extract data using SAS and/or OnePI to identify billing aberrancies and potential fraud schemes.Use SQL to identify data aberrancies and/or abnormalities.

Provided overall coordination, status reporting and stability of PCA Probes of Medicare providers to ensure proper billing and protect the Medicare Trust Fund. Assigns and coordinates Nurse Reviewer audit workloads as well as the tracking and reporting of results of provider probes. Monitors project plans, assignments and work efforts on a daily basis. Participates with data analysis meetings (review claim data, file and claim history) to assist in the selection of possible audits of Medicare claims.- Assisted in determining possible program vulnerabilities works directly with nurse reviews to determine the appropriate corrective actions within Medicare guidelines. Ensures resource needs are assigned appropriately and escalates functional, quality and timeline issues. Assists in creating materials that aid in illustrating analytical/data findings.- Analyzed data for creation of statistical reports used for program or process evaluation. Maintains databases and extracts data for analysis. Runs and reviews reports, analyzing results in support of operational functions. Analyze data results, to determine the source of aberrant statistics and resolve data issues.

Business Administration And Management, General

Bachelor Of Science - Bs, Healthcare Management

Property, Casualty & Life, Insurance & Commerce