Clinical Fraud Investigator Senior Resume Example Anthem Blue Cross

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)

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

Clinical Fraud Investigator Senior Resume Example

Resume Score: 80%

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