Sales Management

Sara Berken

SPECIAL INVESTIGATOR

Special Investigations Unit Humana Insurance Co.

**********@*****.***

Phone: 1-920-***-****

HUMANA INC. (JANUARY 26, 2009 – PRESENT)

SPECIAL INVESTIGATOR

SPECIAL INVESTIGATIONS UNIT

Special Investigator

JOB ACCOUNTABILITIES

Responsible for interviewing and investigation of improper

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conduct involving vendors and all others doing business with

and inside the enterprise.

Experience, Knowledge and ability to prepare legal reports and

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evidence with all required administrative provisional standards

met according to legal statutes.

Fully trained negotiation experience in the two major forms of

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negotiation: Distributive negotiation and Integrative

negotiation.

Fully trained and experienced in multiple forms of

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Interrogation techniques, including but not limited to “Reid

Interrogation Techniques”.

Analyzes fraud trends and recommends appropriate action.

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Information Security and Risk Management for Senior Level

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Management.

Seasoned at conducting special investigations involving

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sensitive and/or complex matters within the company.

Very skilled in Computer Forensic Software and Data-mining:

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Lexis Nexus, Accurint, Access, Excel, Microsoft, Forensic

Accounting, Adobe Forensic Toolkit and Photoshop.

Assists in ensuring legal/regulatory compliance.

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Stays current with changes in laws that affect investigative

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activity (i.e., employment law, laws addressing security, etc).

Conducts a thorough, unbiased investigation and advises

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management of developments to be used for decision making.

At all times, maintains a high level of confidentiality.

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Prepares well written and well documented investigative

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reports for regulatory and law enforcement authorities.

Implement and execute goals and objectives.

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Coordinate investigative matters impacting Fraud/Claims

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abuse for Humana.

Maintain a high level of education regarding fraud issues

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sufficient to provide sound decisions to present to management

and guidance to peers.

Maintain high level of contact with company executives in

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regard to the highly sensitive nature of the Personal Health

Records that I have access to.

Skilled in predictive analytics will help you identify suspect

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events early in the claim, resulting in substantial cost

containment and mitigation.

Direct special examinations and investigations at the request of

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senior management.

Impact morale within the division as well as in other areas of

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the company through consistent administering of all divisional

and corporate policies and procedures.

Develop and maintain a special relationships with

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international, federal, state and local investigative agencies at

all levels.

Ability to increase the effectiveness of the Corporate

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Investigations group by communicating, mentoring and

building strong relationships within all divisions of the

company.

Ability to anticipate changes both within and outside the

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company that impact the business.

Maintain the company’s focus on the importance of a strong

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and effective investigative program through frequent and

clear communication at both management and hourly levels.

Maintain the highest level of integrity and standards within the

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Humana Security Division.

Ensure present and future external resources are identified and

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met in support of Humana investigations.

Have worked with and helped to build evidence with the Office

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of the Inspector General, Attorney General’s office

Prosecutors, Department of Justice.

Ability in assessing existing form agreements and practices to

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analyze and recognize fraud based on contractual agreements.

Knowledge of the medical, healthcare or pharmacy industry

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and skills in clinical setting.

Demonstrated effective organizational and communication

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skills

A valid driver's license and an unblemished driving record

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CLAIMS REVIEW ANALYST

(CLAIMS/FRAUD INVESTIGATION), 01/26/09

– 10/17/10.

Applied experience and knowledge of claims laws and

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coverage.

Applied and In-depth, thorough knowledge of pharmaceutical

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drugs (Both by their brand names and generic names) and

there uses.

Excellent problem-solving skills.

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Experienced in examining policy coverage forms and other

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records to determine insurance coverage

Applied experience performing Interviews, telephone, or

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correspond with claimants and witnesses.

Applied experience and knowledge in Receiving, documenting

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and resolving customer inquiries by using established best

practices.

In depth knowledge of multiple forms and areas of FRAUD,

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WASTE and ABUSE.

Builds lasting relationships with Humana’s customers

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Educates customers and providers regarding HumanaOne’s

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products and services over the telephone.

Begin Cases on Material Misrepresentation. Request the

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records, read and understand the medical implications found

in the records and be able to verify if I can apply pre-x as well

as read through the medical records for any evidence of

Material Misrepresentation based upon the laws mandated by

each state. I then get to make a case decision to either refer it to

Underwriting, or close it as a case complete.

Data analysis and Fraud/Waste and Abuse Investigation

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procedures.

Knowledge of claims laws and coverage’s.

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Excellent verbal and written-communication skills and

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problem-solving and negotiation skills.

INDEPENDENT NURSING SERVICES INC. (1992-2003)

C ERTIFIED N URSE ’ S A IDE – 1 992 – 1994; M Y D UTIES

W ELL - BEING .

I NCLUDED PATIENT C ARE A ND

SCHEDULING S ECRETARY – 1 994 - 1995; M Y D UTIES

I NCLUDED B UT WAS N OT L IMITED T O C USTOMER - RELATED

S ERVICES, P LACEMENT, M ANAGING M ULTIPLE C USTOMER

S CHEDULES, P ROBLEM S OLVING, R ESOLVING S TAFF C OMPLAINTS .

S TAFF P LACEMENT, C OORDINATING A ND R ESOLVING P ROBLEMS

W ITH S CHEDULING D IRECTOR .

D IRECTOR S CHEDULING 1 995 – 1997; D UTIES

OF

I NCLUDED B UT WAS N OT L IMITED T O C USTOMER - RELATED

S ERVICES, O VERSEEING S CHEDULING S ECRETARIES, M AINTAINING

S TAFFING L EVELS .

Director of Human Resources - 1 997-2003;

supervised sales support staff to ensure the efficient, accurate and

timely completion of all processes and transactions that affects

sales results. Explain and enforce policies and procedures

consistent with I.N.S.I. guidelines and goals, identifying and

developing methods for continuous improvement at all levels.

Ensure Market Office runs in a seamless manner through

oversight of support staff. Actively engage with and support

outside partners in growing and retaining sales acquisitions

within the market. Customer-related services including targeted

recruiting, screenings, hiring, training, orientation and problem

resolution, Employee Relations Management. Overseeing entire

staffing department, making sure that all employees remained up

to date on all trainings, vaccinations (As is required for State of

Wisconsin Nursing Regulations) yearly, monitoring contract

compliance and reporting.

Provided Recommendations towards Sales and Marketing

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solutions based on understanding and evaluation of trends,

dynamics, customer needs, and competitors’ products or services.

Participated in and helped to create; Sales and Marketing

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meetings, training programs conventions and displays as

appropriate.

Understanding of most up-to-date clinical studies to educate

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customers and improve ability to anticipate and handle

questions/concerns about products.

Continuously promote and improve knowledge of I.N.S.I.’s

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products, competitive products, and sales and promotional skills

through participation in company sponsored/approved training

programs.

Highly skilled in Identifying and responding to obstacles in use of

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I.N.S.I.’s products.

Continuously developing and maintaining a mastery of products

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knowledge and consultative promotion techniques

Ability to develop a customized approach for each call on each

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customer to assess customer needs and increase sales of

Companies products.

__________________________________________________________

During this period (2003 2009), I took some time

off to raise my children).

EDUCATION

Notre Dame Academy

High school diploma

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N.W.T.C

Certified Nursing Assistant Certification: 1 year of

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General Education Completed, 2 years in Registered

Nursing Program, Medication Administration

Certification, Applied and Comprehensive and working

knowledge and understanding of Medical Terminology,

Innovation Implementation.

I.N.S.I. Trainings and Courses

Strategic Thinking, Leading and Motivation, Accounting,

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Strategy Execution, Negotiation styles – Distributive

negotiation and Integrative negotiation, The Four Forms of

Business Writing, Microsoft Office, Excel, Lotus Notes,

Access and PowerPoint, Communication Business Etiquette,

Discretion and Business Ethics, Business Management - Dual

Focus, Business Management - Employee Trust, Business

Management – Strategy.

Humana Trainings and Courses

Information Security and Risk Management for Senior Level

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Management, Forensic Accounting, Managing Upward,

Object-Oriented Analysis and Design, Negotiation techniques

- Persuading Others, Reid Interrogation Techniques,

Excel/Access/PowerPoint, Adobe Forensic Toolkit and Adobe

Forensic Photoshop, National Audit (Pharmacy), Reviewing

pharmacy/medical comparison report, Medical Records

Management Microsoft Outlook, What is Negotiation,

Planning for Negotiation, Communicating and Persuading,

Business Etiquette, Investigating Provider Credentialing and

Board Certification, Advanced Training Federal Health Care

Fraud and Abuse Laws, Navigating the Fraud and Abuse”,

Laws”, “The False Claims Act”, “Understanding the

Consequences of Health Care Fraud - Including 1. Referrals

2. Items/Services 3. Intent 4. Exceptions”, “Importance of

Documentation”, “Understanding Program Exclusions”,

“The Stark Laws”, “Anti-Kickback Statute”, Investigating

Eligibility and Agent cases, Coding and ICD 10 release, Tech

Consultant JXC Draft Learning course, Planning and

Securing a DB2 UDB Database, IBM DB@ Universal

Database 5.0, Accessing Data and Manipulating Data, Cisco

Internetwork Troubleshooting, CISSP Domain – Access

Control, Technical Support Essentials, Data Mining – Full

Training implemented quarterly to stay up-to-date on newest

methods and products, Investigation & Management of

Corporate Fraud. Special Investigations Interventions for J

codes billing fraud schemes.

UWGB

Currently taking “CLEP” exams to finish “Political Science”

Bachelor’s Degree through U.W.G.B.

Contact this candidate