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Clinical Fraud Investigator Senior Resume Example

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CLINICAL FRAUD INVESTIGATOR SENIOR
Accomplishments
Professional Summary
Registered Nurse, CPC and 18 1/2 years with Anthem. Experience with leadership, demonstrating strong analytical and problem solving skills, working in Fraud & Abuse and computer proficiency.
Skills
  • Experienced manager and trainer
  •  Multi-tasks to prioritize and increase productivity
  •  Health care Industry experience 19 years with Anthem system's - Mainframe, WellPoint Content Framework (records), WMDS, Metric Stream, Velocity Report, 
  • Excellent verbal and written skills, proficient in Microsoft Word, Excel, Outlook and PowerPoint
  •  Perform detailed auditing/analysis of medical records
  •  Fast learner, Highly dependable, problem solver
Work History
Clinical Fraud Investigator Senior, 05/1998 to Current
Anthem Blue Cross – 2000 Corporate Center Drive, Newbury Park, CA 91320
  • Currently working as Clinical Investigator for the past 6 ½ years doing investigations, Pre-payment review and data mining for outliers.
  • MIU/NIQRT/MRU - Management of 30 direct reports 9/2008- 6/2010.
  • Researched CPT and ICD-9/ICD-10 coding discrepancies for compliance and reimbursement accuracy.
  • Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.
  • Maintained updated knowledge of coding requirements, through continuing education and certification renewal.
  • Resourcefully used various coding books, procedure manuals and on-line encoders.
IV Visiting Nurse, 01/1997 to 11/1998
Livingston Visiting Nurses - LVNA – Ventura, CA
  • Independently visited patients at their residence - documenting procedures performed and patient's condition.
  • Reporting to Physician any abnormal conditions.
Registered Nurse, 01/1992 to 01/1997
ST John's Hospital – Oxnard, CA
  • Pediatric/Medical-Surgical floor nurse, Nurses' assistant while completing RN.
Education
AA/AS: Nursing, May 1994
Ventura College - Ventura, CA
Certifications

  • Registered Nurse (RN)
  • Certified Professional Coder (CPC)
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Resume Overview

Companies Worked For:

  • Anthem Blue Cross
  • Livingston Visiting Nurses - LVNA
  • ST John's Hospital

School Attended

  • Ventura College

Job Titles Held:

  • Clinical Fraud Investigator Senior
  • IV Visiting Nurse
  • Registered Nurse

Degrees

  • AA/AS : Nursing , May 1994

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