Description :

1. Conducted comprehensive benefit verifications to ensure accuracy in patient claims.
2. Engaged with Pharmacy Benefit Managers and major insurance companies to resolve complex inquiries.
3. Collaborated daily with Medicare and Medicaid to streamline patient coverage processes.
4. Executed test claims using Scriptmed to assess medication coverage efficiently.
5. Exceeded daily quotas while assisting physicians with prior authorizations and documentation.
6. Maintained consistent follow-up on prior authorization statuses with insurance companies and medical offices.
7. Facilitated timely access to medications for patients, enhancing their healthcare experience.

Experience

0-2 Years

Level

Entry Level

Education

B.S. Criminal Justice

Description :

1. Managed investigations for the State of Kansas and Missouri, conducting over 300 investigations annually.
2. Evaluated multi-line insurance claims, coordinating with legal counsel and law enforcement.
3. Executed thorough interviews and surveillance to gather evidence and insights.
4. Generated detailed reports leveraging the TRAVIS database for consistent documentation.
5. Partnered with law enforcement agencies to address fraudulent claims.
6. Referred approximately 35 fraudulent claims per year for prosecution.
7. Identified suspicious claims, resulting in projected annual savings of $1.8 million.

Experience

5-7 Years

Level

Senior

Education

B.S. Criminal Justice

Description :

1. Investigated auto and property insurance claims, evaluating coverage applications according to policy terms, determining liability, and assessing fraudulent activities.
2. Conducted thorough assessments of claimed injuries, reviewing treatment plans, evaluating medical bill coding, and negotiating settlements with medical providers.
3. Authorized settlements in compliance with policy provisions, effectively managing risk for the company.
4. Managed an average of 150-200 active case files, coordinating all activities from first notice of loss to final resolution.
5. Consistently met legal deadlines for investigations and settlements, ensuring compliance with regulatory standards.
6. Exceeded performance benchmarks for investigative thoroughness, customer satisfaction, and quality audits, maintaining 100% consistency.
7. Served as the Team Employee Engagement Coordinator, organizing initiatives based on employee feedback to enhance workplace morale.

Experience

5-7 Years

Level

Senior

Education

B.S. in CJ

Description :

1. Conducted thorough first and third-party investigations into suspicious insurance claims, ensuring accurate evaluations of fraud risk.
2. Managed investigative assignments across a five-state region, coordinating vendor activities to optimize resource allocation.
3. Collaborated effectively with law enforcement, claims teams, and attorneys to gather evidence and resolve complex cases.
4. Produced detailed investigative reports outlining findings and recommendations, enhancing decision-making processes.
5. Facilitated ongoing fraud awareness training for claims personnel, resulting in heightened vigilance and proactive fraud detection.
6. Authored several articles on insurance fraud best practices, contributing to industry knowledge and awareness.
7. Actively participated in professional organizations, staying updated on industry trends and networking with peers.

Experience

2-5 Years

Level

Executive

Education

B.S. Criminal Justice

Description :

1. Verified patient insurance benefits, ensuring accurate documentation for billing.
2. Obtained pre-authorization for claims, maintaining compliance with insurance protocols.
3. Reviewed after-hours admissions to ensure proper documentation and follow-up.
4. Coordinated with insurance providers to resolve discrepancies in claims processing.
5. Conducted interviews to gather information and evidence for claims investigations.
6. Documented findings and prepared reports for claims assessment.
7. Collaborated with cross-functional teams to improve operational efficiency.

Experience

10+ Years

Level

Executive

Education

B.S. Criminal Justice

Description :

1. Conduct thorough investigations of insurance claims to detect fraud and ensure compliance.
2. Evaluated and negotiated settlements for a range of injury cases, ensuring fair resolutions.
3. Prepared timely responses to legal documents, maintaining compliance with industry standards.
4. Maintained accurate records and status updates as mandated by regulatory agencies.
5. Coordinated appointments and meetings to facilitate claims processing and stakeholder communication.
6. Adapted to urgent assignments by prioritizing tasks and reorganizing daily responsibilities.
7. Handled sensitive cases involving fatalities with professionalism and urgency to support affected parties.

Experience

2-5 Years

Level

Executive

Education

B.S. Criminal Justice

Description :

1. Conducted comprehensive investigations into insurance fraud, including surveillance, background checks, and interviews.
2. Drafted detailed reports and submitted evidence to support claims evaluations.
3. Testified at hearings and depositions as required.
4. Collaborated with industry professionals to enhance investigative outcomes.
5. Managed a diverse caseload independently, ensuring thorough follow-ups.
6. Verified medical coverage and pre-certifications for claims processing.
7. Documented and tracked investigation findings for compliance and reporting purposes.

Experience

0-2 Years

Level

Fresher

Education

B.S. Criminal Justice

Description :

1. Conducted in-depth investigations into suspected fraudulent claims, utilizing advanced analytical techniques.
2. Coordinated with law enforcement and regulatory agencies to ensure compliance and facilitate prosecutions.
3. Mentored new investigators, providing training on investigative best practices and compliance standards.
4. Managed case files and documentation to ensure accuracy and adherence to company protocols.
5. Analyzed data trends to identify potential fraud patterns and inform strategic decision-making.
6. Prepared detailed reports summarizing investigative findings and recommendations for management.
7. Maintained up-to-date knowledge of industry regulations and fraud detection methodologies.

Experience

5-7 Years

Level

Management

Education

B.S.CJ.

Description :

1. Conducted comprehensive investigations into complex claims, identifying potential fraud cases.
2. Reviewed documentation and evidence to establish case objectives and meet client expectations.
3. Prepared detailed reports outlining findings, conclusions, and recommendations for claims resolution.
4. Maintained accurate records and timely updates on ongoing investigations.
5. Ensured compliance with legal and regulatory standards throughout the investigation process.
6. Collaborated with various stakeholders to gather necessary information for case analysis.
7. Executed surveillance and undercover operations as needed to gather evidence.

Experience

2-5 Years

Level

Junior

Education

B.S. CJ

Description :

1. Conducted detailed investigations into suspicious claims and potential fraud cases.
2. Collaborated with the SIU manager to develop strategic plans for investigation.
3. Established daily investigative objectives and tracked progress.
4. Communicated effectively with referral sources to verify investigation needs.
5. Gathered and analyzed evidence from various stakeholders.
6. Prepared comprehensive reports outlining findings and recommendations.
7. Performed database checks to validate claims and uncover discrepancies.

Experience

7-10 Years

Level

Management

Education

B.S. Criminal Justice