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Summary

Dedicated and vigilant individual with 10 years’ extensive experience in investigation services. Demonstrated expertise in investigative/analytical techniques, and a strong know-how of contemporary trends in fraudulent activities.Utilizing modern technology to combat fraud, waste, abuse and make appropriate recommendations. Knowledgeable in numerous investigative tools, surveillance, intelligence and risk management

History

Lead Investigator

CMS: Centers for medicare & Medicaid Services (contract)
2015Present
  • Use a variety of tools to assist in the development of investigations to identify potential fraud. Development of investigations include: responding to requests for data and support, analyzing and interpreting claims data for aberrance's  conducting interviews, and reporting findings with a focus on taking quick and appropriate follow up actions.
  • Follow up actions commonly include: referrals to law enforcement, provider education, and initiating overpayment recovery, along with other administrative actions.
  • Appear in court to testify about work findings. Perform research and draw conclusions. Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
  • Organize a case file, accurately and thoroughly document all steps taken. Compose correspondence, reports and referral summary letters. Educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups.

SIu: Manager

Estrella Insurance Company
20122015
  • Investigation of claims that may contain elements of fraud or claims otherwise deemed suspicious in nature. The investigator will complete said investigation in a prompt manner and in partnership with the claims handler assigned.
  • Evaluate the claim and provide claims staff with their analysis of each investigation. Identify any fraud trends or techniques in assigned jurisdiction and report those trends to the Claims Analyst team in Home Office.
  • File using appropriate field, computer and telephone investigative techniques and provides appropriate documentation of actions in a thorough timely manner. Prepare necessary reports for state fraud bureaus and cooperates with state agencies as required by law and management.
  • Keep the Special Investigation Unit and field managers advised of all critical situations. Report findings of all investigations and makes recommendations to the responsible manager or other designee in a timely manner so as to facilitate prompt decisions.

In house investigator 

LAw firm
20092012
  •  Provide investigative expertise to direct and conduct investigations. Analyze, organize, and investigate multi-line types of investigations. Ensure the accuracy, quality, and timeliness of investigations.

  • Effectively apply advanced knowledge of laws, legal codes, court procedures, precedents, government regulations, executive orders, and agency rules to investigations.    

  • Prepare and present completed investigations to appropriate lawyers in a highly professional manner and provide superior communication, customer service and ensure relationship building with all integral personnel Prior work experience can be provided upon request.

Certifications

CFE

Certified fraud EXAMINIER 

State of florida

PRIVATE INVESTIGATOR

Education