Medical Quality Assurance

NANCY CASTORENA

310-***-**** ( *****.******@*****.***

objective

To utilize my auditing, investigations experience and operational skills to

advance the organization to a higher level of performance. Bi-lingual in

Spanish.

Experience

10/09 - 01/10/11 CalOptima

Supervisor

. Manage and direct the day-to-day operations of three teams;

Auditing team, Recovery Team and Claim Customer Service team

with optimal monthly results.

. Responsible for following regulatory and internal guidelines in

Managed Care including Medi-Cal, Medicare and commercial

policies and payment procedures.

. Monitor staff to insure that auditors identify billing trends

that have an adverse financial impact to this company. Work

closely with Contracting Department and Provider Relations

Department to provide the medical community with payment-claims

information.

. Report error trends and compile reports on errors occurring due

to system configurations and examiner error.

. Monitor and actively pursue recovery opportunities in accordance

with regulatory standards.

. Identify providers that have a pattern of aberrancies in billing

and recommend to Fraud and Compliance.

. Monitor and actively participate in education and identification

of aberrancies and over- payments related to claims submissions.

. Ensure appropriate monitoring of claims payment and feedback

provided to claims staff in a timely manner, to include tracking

and trending errors for development of documentation and

provider education.

11/08 - 2/09 Horsemen Investigations

Worker's Comp -Statement Investigator

. Conduct interviews of claimants and employers and obtained

recorded statement on alleged work injuries.

. Responsible for gaining thorough and detailed information on job-

related incidents to determine the cause and the result of work

environments.

. Performed Bi-lingual interpretation of claimant's interviews.

. Reported to insurance companies' background of claimants and

witnesses in order to determine if reports of work injuries and

statements were legitimate.

7/08 - 8/08 Martino Consulting and Investigative Services, Inc.

Investigator - Temporary assignment

. Assisted the Los Angeles City Attorney's office in their

investigation of Medicare/Medi-Cal Fraud and the Skid Row

dumping of patients by two Los Angeles hospitals and two

ambulances companies.

. Performed surveillance in the Los Angeles Skid Row area for the

City Attorney's office.

. Conducted interviews of homeless personnel in order to obtain

information on the schemes to defraud Medicare/Medi-Cal by

ambulance companies and hospitals.

NANCY CASTORENA

310-***-**** ( *****.******@*****.***

2/04 - 11/07 SafeGuard Services (SGS) - Benefit Integrity Support

Center

Fraud Investigator

Developed and conducted confidential and thorough unbiased investigations

of Medical fraud. Analyzed and evaluated suspected fraud claims through

performance and origin of cause. Summarized and documented investigative

findings and made appropriate recommendations to management, FBI, OIG and

the office of AUSA. Evaluated weaknesses in company's functions and

processes and worked closely with the auditing department and the Center

for Medicare and MediCaid Services to make appropriate changes that insured

meeting government regulations.

Job Accountabilities:

. Conducted interviews with patients/ beneficiaries and physicians

regarding services that were never rendered such as office

visits, medical treatments and diagnostic treatments.

. Performed data mining and detailed data analysis to determine

ownership of facility whereby the owner has undisclosed

financial interest.

. Reviewed and interpreted complex medical records and complex

claims to determine fraud or abuse.

. Strong understanding of diagnosis, CPT codes, HCPC codes and

medical terminology.

. Recommended to management and CMS on the mandate for physician's

to submit medical records with billing submissions. Worked

closely with Medical consultants in the review of medical

records.

. Prepared investigative reports and referred fraud cases to law

enforcement such as kickbacks and illegal financial

relationships among Independent Diagnostic Testing Facilities,

Ambulance companies, Durable Medical Equipment, physician and

Physician Assistants.

. Executed on-site investigations, conducted extensive audits.

. Established and maintained liaisons with federal, state and

local criminal justice agencies.

. Developed and provided fraud training to various external and

internal entities.

. Worked independently with little and sometimes no supervision.

. Conducted interviews with physicians in a diplomatic and

respectful manner to insure that the highest level of

communication and quality of interview was performed.

6/03 - 1/04 National Heritage Insurance Company (NHIC)

Medical Review Compliance Officer/Auditor

Job Accountabilities:

Reviewed medical records and worked closely with nursing staff to

implement audits and edits that allowed the suspension of claims for

medical records review by nursing staff.

. Managed and implemented quality assurance program for Medical Review

Department.

. Performed statistic-driven audits, documented and reported control

objectives, monitored goals, activities and accomplishments.

. Communicated audit findings with staff and CMS.

. Identified issues that caused changes in claims workflow and

recommended changes in procedures and processes to meet CMS timeliness

requirements.

. Co-authored California LPET Strategy Report with NHIC Medical Director

for submission to CMS.

. Trained personnel on edit and audit systems.

5/00 - 5/03 National Heritage Insurance Company (NHIC)

Claims Supervisor

. Managed day-to-day operations of Specialty Claim Unit who handled

complex claims and review of medical records.

. Collaborated with other departments to improve the processing of

claims.

. Administered audits, budget and workload review.

. Developed related training and provided training to claims personnel.

. Prepared management reports on claim activity, results and trends.

. Trained, coached and counseled subordinates to meet customer needs and

department quality standards.

. Led team to exceed government's quality standards for Medicare claims

processing and timeliness.

. Evaluated performance of direct reports and provided constructive

feedback that enhanced performance.

. Develops policies, procedures and standards for all department

activities.

NANCY CASTORENA

310-***-**** ( *****.******@*****.***

6/86 - 5/00 Transamerica Life Insurance Company

Claims Supervisor

. Supervised 24 claims examiners; maintained the integrity of claims

processed.

. Provided analysis of services and statutory requirements.

. Reviewed claims by performing audits for propriety and potential

fraudulent activity.

. Consistently exceeded Medicare quality assurance guidelines. Processed

claim receipts in 33% less time than Medicare regulations; exceeded

time requirement by processing 99.6% of all claims within the

guidelines.

EDUCATION AND CREDENTIALS

. East Los Angeles College--Liberal Arts Studies

. Association of Certified Fraud Examiners: (ACFE)

. National Health Care Anti-Fraud Association (NHCAA)

SKILLS

. Proficient in MS Windows. Skilled in Outlook, MS Office, including

Word, Excel and Business Objects.

. J.Reid Courses -classroom studies (32 hours) of interview and

interrogation techniques

. Former Member of NHCAA

Contact this candidate