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Skills

  • Recovered payments reconciliation
  • Managing claims with Tableau
  • Fraud prevention techniques
  • Advanced Interviewing Techniques
  • Problem resolution
  • Claims handling time optimization
  • Cross-functional team collaboration
  • Investigation report preparation
  • Insurance fraud detection
  • Process improvement

Work Experiences

  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Achieved cost recoveries of over $12.
  • Achieved successful settlements worth $9.
  • Gathered and tracked evidence in support of legal processes.
  • Oversaw claim negotiations within a $17 budget and assisted in successful litigation for complex issues.
  • Boosted cross-departmental awareness by 23%.
  • Determined liability as outlined in the coverage and assessed documentation from police and healthcare providers to understand the damages incurred.
  • Achieved minimal litigation.
  • Applied findings to claims cases.
  • Reviewed police reports, medical treatment records, and physical property damage to determine the extent of liability.

Summaries

  • Costs were consistently reduced while profits were increased.
  • Accomplished investigator specializing in insurance fraud and compliance. Recognized for uncovering fraudulent activities in 2023, leading to operational savings and a 49% decrease in fraudulent claims.
  • Accomplished Insurance Claims Investigator.
  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Proven track record of using excellent negotiating skills to speed up settlements.
  • Accomplished Insurance Claims Investigator specializing in identifying fraudulent patterns within claims data. Uncovered $4 in fraudulent claims utilizing advanced analytics tools over a span of the past year, contributing to significant cost savings.
  • Achieved a 24% decrease in fraudulent claims.
  • Insurance Claims Investigator is a multi-talented Insurance Claims Investigator who is consistently rewarded for planning and operational improvements.
  • Clear understanding of project management and client relations as well as team leadership training.
  • Within Miscellaneous, senior Insurance Claims Investigator and outstanding performer in project management and process improvement.

Accomplishments

  • Developed and implemented an enhanced evidence collection workflow that reduced investigation turnaround times by 42%.
  • Reduced average claims investigation time by 67% by implementing new risk-based investigation methodologies using ServiceNow.
  • Supported the legal team in uncovering critical evidence, leading to the successful defense of 14 litigation cases, saving over $15 in potential claims costs.
  • Recovered $12 in indemnity payments by closely analyzing policy details and challenging suspect claims in court proceedings.
  • Successfully negotiated settlements, saving the company $2 while adhering to legal precedents and regulatory guidelines.
  • Reviewed uploaded surveillance footage and cross-validated with third-party reports to refute false claims for over $4 worth of insurance requests.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Resolved inter-departmental barriers by streamlining communications between legal, adjusters, and investigators, reducing false claim payouts by $8.
  • Increased regulatory compliance adherence by 69% through thorough reviews and implementation of audit recommendations related to category.
  • Uncovered fraudulent claims using advanced social media search and monitoring tools, resulting in the prevention of payouts exceeding $8.

Affiliations

  • National Fire Protection Association (NFPA)
  • American Medical Informatics Association
  • International Association of Special Investigation Units (IASIU)
  • Institute of Risk Management (IRM)
  • International Association of Administrative Professionals
  • Freemason
  • National Insurance Crime Bureau (NICB)
  • International Institute of Certified Forensic Investigation Professionals (IICFIP)
  • Council on Litigation Management (CLM)
  • Lions Club

Certifications

  • Certified Insurance Fraud Investigator (CIFI) – Summit Group
  • Associate in Risk Management (ARM) - Harbor & Co.
  • Certified Claims Professional (CCP) - Cedar Works
  • Certified Fraud Examiner (CFE) - Northwind
  • Certified Public Accountant (CPA)
  • Google Certified Professional Cloud Architect
  • Fellow, Life Management Institute (FLMI) - Meridian
  • Certified Liability Insurance Adjuster (CLIA) - Ironclad Systems
  • Claims Litigation Management (CLM) Fellow - Summit Group
  • Senior Claim Law Associate (SCLA) – Brightline

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