Description :

1. Conducted a thorough benefit verification for each patient.
2. Spoke with Pharmacy Benefit Managers as well as the Medical side of major insurance companies as well as smaller ones.
3. Spoke with Medicare and Medicaid on a daily basis.
4. Ran test claims using Scriptmed to find out coverage on medications.
5. Met a quota on a daily basis Assisted doctor's with prior authorizations by sending correct forms to their office or finding what other method could be used to complete it.
6. Followed up on the prior authorization status with the insurance companies as well as doctor's office.
7. Helped many patients get their much needed medications in a timely manner.

Experience

2-5 Years

Level

Executive

Education

Diploma

Description :

1. Assigned to a single investigator office responsible for the State of Kansas and the western half of the State of Missouri, resulting in over 300 investigations conducted per year.
2. Investigated multi-line insurance claims from initial referral through final law enforcement referral.
3. Investigation process included conducting numerous interviews, recorded statements, assisting legal counsel with depositions, performing surveillance and obtaining criminal and civil information from computer data base searches utilizing the National Insurance Crime Bureau (NICB) database, Property Insurance Loss Registry (PILAR) and other data mining services.
4. Prepared detailed investigative reports utilizing the Travelers Investigative Service (TRAVIS) database system.
5. Coordinated with law enforcement and other state agencies.
6. Each year, referred an average of 35 suspected fraudulent claims to State and County agencies for potential prosecution.
7. Identified questionable, suspicious or fraudulent claims resulting in projected yearly savings of $1,800,000.

Experience

10+ Years

Level

Senior

Education

Bachelor Of Science

Description :

1. Investigated auto and property insurance claims, evaluating applications of coverage according to policy contract terms and conditions, determining liability, assessing fraudulent activity, preparing and analyzing evidence for use by subrogation, legal, and special investigative units, and negotiating cost-effective settlements with policyholders, claimants, and attorneys.
2. Assessed claimed injuries, reviewed scheduled treatment plans, evaluated medical bill coding, examining records for accuracy, and negotiating settlements with medical providers, policyholders, and attorneys.
3. Authorized to commit the company to settlements in accordance with the provisions of each policy contract.
4. Managed an average of 150-200 case files at any given time, with responsibility for coordinating all activities as primary file handler from first notice of loss until final settlement.
5. Met legally required deadlines for handling and settlement.
6. Regularly exceeded standards for investigative completeness, customer satisfaction, and affiliated repair assignment ratios and maintain 100% consistency in quarterly internal audits for file quality.
7. Served as a Team Employee Engagement Coordinator, organizing events and providing feedback in a team based initiative based upon responses to the Gallup Employee Engagement Survey.

Experience

5-7 Years

Level

Executive

Education

MA In History

Description :

1. Conducted external first and third-party insurance investigations involving suspicious insurance claim activity.
2. Oversaw a five-state region and facilitated investigative assignments accordingly managing outside vendor activity.
3. Worked closely with various law enforcement entities, claims personnel, as well as defense and plaintiff attorneys throughout the region.
4. Completed numerous timely, thorough, and objective insurance investigations with subsequent descriptive reports which detailed all investigative activity.
5. Routinely conducted ongoing fraud awareness training to claims personnel and participated in several insurance fraud seminars.
6. Authored three insurance fraud articles.
7. Membered of several professional insurance investigator organizations (OAISIU, NSPII, and NAFI).

Experience

7-10 Years

Level

Management

Education

GED

Description :

1. Verified patient insurance benefits, sending written documentation to Hospital and Outpatient facilities.
2. Obtained pre-authorization and pre-certification when needed, ensuring the correct insurance agency, and the information is timely and noted in the patient's financial chart.
3. Verified documentation on after-hours admissions and follows up on day admissions.
4. Verified that appropriate documentation was obtained for all after-hour admissions done by an after hour specialist.
5. Completed patient's financial folder.
6. Acquired any missing documentation.
7. Loaded insurance payor guarantors based on payor for billing.

Experience

7-10 Years

Level

Management

Education

GED

Description :

1. Conducted interviews of parties involved, scene investigations and met with attorneys, and appeared in small claims court hearings.
2. Evaluated, negotiated, and settled soft tissue to serious injury cases.
3. Prepared responses to time-sensitive documents in a timely manner.
4. Maintained diary of all files, inclusive of status letters as mandated by California Department of Insurance.
5. Organized appointments and meetings to accommodate the needs of the claims office.
6. Handled time-sensitive/rush assignments as priorities by re-organizing daily duties as needed.
7. Conducted business in a professional and time-sensitive manner when dealing with fatalities or catastrophic losses.

Experience

10+ Years

Level

Senior

Education

MS

Description :

1. Conducted full investigations related to insurance fraud, including surveillance, activity checks, background checks, locates, and statements.
2. Wrote reports and submitted them with video evidence to the field office.
3. Testified as needed at hearings.
4. Worked closely with professionals in the industry.
5. Managed own caseload and work independently in the field.
6. Verified medical coverage for inpatient and surgical admissions.
7. Obtained Pre-certifications/authorizations prior to admission.

Experience

5-7 Years

Level

Executive

Education

BA In Economics

Description :

1. Billed Medicare, BCBS, and Medicaid inpatient claim once authorization obtained.
2. Served as a team mentor for new staff, assisting with training incoming employees on company processes and essential job skills.
3. Prioritized investigations while maintaining the standards of timeliness, thoroughness, and timely reporting.
4. Responsible for the operational and administrative activities associated with a one-person office, including coordinating and monitoring outside investigative contractors.
5. Conducted investigations for doctor's offices to let them know the cost or whether the medication would be covered before it was prescribed to the patient.
6. Managed several cases simultaneously on a daily basis Skills Used Communication skills to get the proper information that was needed.
7. Conducted insurance claims investigations, including taking recorded claimant and witness statements as well as performing scene investigations.

Experience

2-5 Years

Level

Junior

Education

GED

Description :

1. Completed multiple types of complex claims investigations.
2. Reviewed assignments and supporting documentation to determine case objectives and client expectations.
3. Daily submissioned of updates regarding work performed on each case.
4. Maintained a sufficient level of client billable hours.
5. Prepared and dictated detailed investigation reports.
6. Adhered to strict due dates.
7. Worked independently.

Experience

5-7 Years

Level

Executive

Education

GED

Description :

1. Worked from a home-based office and work flexible hours.
2. Assisted SIU manager with duties to include special projects.
3. Established an investigative plan on a daily basis.
4. Received referral, communicate with referring sources, verify need for investigation and document all appropriate information.
5. Initiated investigation by gathering facts and evidence with all interested parties.
6. Completed appropriate reports.
7. Ran appropriate database checks.

Experience

5-7 Years

Level

Executive

Education

High School Diploma