Conducted Medicare/Medicaid investigations/audits with Unified Program Integrity Contractor (SEUPIC) to identify aberrant/fraudulent billing including, but not limited to DME’s, no-prior relation Providers (NPR), services not rendered (SNR), Credit Balances, Managed Care Provider/Organization (MCP/MCO). Collaborated with other agencies such as CMS, Medicaid Fraud Control Unit (MFCU), Medicare Advantage Contractor (MAC), I-MEDIC, and Office of Inspector General (OIG) for law enforcement activity. Immediate advisements (IA) filed as needed.

Conducted investigations/interviews for monitoring/auditing on providers with high-risk adjustments payments.Performed high level desk reviews on Providers’ billing to determine anomalies for fraudulent billing and to ensure proper reimbursement. Executed corrective action plans (CAP), as needed; placed providers on Pre-Payment Review and/or Post-Payment Review. Collaborated with Centers for Medicare & Medicaid Services/Department of Health and Human Services (CMS/HHS) to detect fraud, waste, and abuse (FWA).Humana Association Experience Champion 2018. Humana Technologist Degree.

Analyzed/processed disability claims/applications for eligibility determination. Knowledge of medical terminology.Interviewed claimants, attorneys, and physicians for additional information as needed.

Assisted judge in courtroom matters; Adjudicated cases, swearing-in of witnesses, attorney appointed to litigants.Processed/signed Order of Temporary Custody (OTC) forms filed by Department of Children and Families (DCF), Take-into-Custody (TIC), WRITS/habeas, and warrants as ordered by judge. Scheduled motions onto docket.

Processed/analyzed Medicaid Long Term Care (LTC) applications for eligibility; recertification of such.Recoupment of nursing home claims. Deferred cases as needed.

Maintained/reconciled accounts receivable, accounts payable, and general ledger books. Daily deposits to bank.