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changes007 User

@changes007user

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Accomplished Director of Investigations with expertise in fraud prevention.

United States

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What I'm looking for

I seek a role that values strategic leadership and offers opportunities for professional growth in fraud prevention and compliance.

I am an accomplished Director of Investigations with extensive experience in directing investigations into claims of fraud, waste, and abuse within the Healthcare Insurance industry. My results-driven approach and strategic leadership have enabled me to lead teams effectively, maximizing recoveries while implementing safeguards to close gaps and vulnerabilities.

Throughout my career, I have demonstrated exceptional management skills, training and mentoring teams to consistently meet and exceed performance targets. I have successfully navigated complex investigations, increasing referrals to law enforcement partners and regulatory agencies significantly. My commitment to quality and compliance has been pivotal in bolstering operational efficiencies and ensuring adherence to regulatory standards.

Experience

Work history, roles, and key accomplishments

Current

Director of the Special Investigations Unit

Current

AmeriHealth Caritas Family of Companies

Jul 2021 - Present (3 years 11 months)

Leads the Special Investigations Unit operations, managing a team of investigators to address fraud, waste, and abuse in healthcare insurance. Achieved a recovery of $11.4M within the first year and improved case referrals to law enforcement by 76%. Serves as a trusted advisor and represents the company with regulatory agencies.

Team Leadership Strategic Planning Compliance Data Analytics Performance Management Quality Control Cross Functional Collaboration

Manager of the Special Investigations Unit

AmeriHealth Caritas Family of Companies

Sep 2019 - Jul 2021 (1 year 10 months)

Directed a team of investigators, managing case assignments and audit documentation. Acted as a subject matter expert for fraud issues, leading investigations and litigation support.

Fraud Investigation Team Leadership Stakeholder Engagement Compliance Training Mentorship

Manager 1 – Special Investigations Unit

Anthem Inc.

Aug 2020 - Jul 2021 (11 months)

Supported the Director in strategic direction for the Fraud & Abuse department, supervising investigators and developing case strategies. Managed case intake and analytics, ensuring compliance with state and federal regulations.

Fraud Investigation Team Management Data Analytics Compliance Performance Tracking Training

Investigator, Special Investigations Unit

AmeriHealth Caritas Family of Companies

Mar 2018 - Oct 2019 (1 year 7 months)

Conducted investigations into fraud claims, utilizing data analytics to identify trends. Engaged with various stakeholders to gather evidence for criminal and civil actions.

Data Mining Stakeholder Engagement Analytical Skills Compliance Interviewing

Supervisory Special Agent

Louisiana Department of Justice

May 2013 - Mar 2018 (4 years 10 months)

Oversaw criminal investigations into Medicare and Medicaid fraud, collaborating with law enforcement. Provided training and mentorship to staff and testified in judicial proceedings.