Manager Medical

Michael J. Widner

**** ******** *****

Folsom, CA 95630

Cell 916-***-**** **********@***.***

WORK EXPERIENCE:

UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER

October 2017-January 2018

Senior Privacy and Compliance Investigator

Responsible for managing, implementing, and performing all Privacy and Compliance investigations. Developing an investigative response regarding issues of improper activities, privacy breaches, fraud, waste and abuse, drug diversion, improper business activities, and billing irregularities. Coordinates complex investigative plans to completion including managing department efforts across Compliance and Privacy teams and provides direction and guidance to affected departments. Conduct extensive data analytics, analyze and interpret laws, regulations, and policies. Work with Law Enforcement and Regulatory Agencies. Conduct interviews with the parties involved, compose an investigative report to include a corrective action plan, and serve as a liaison with Academic Personnel, Labor Relations and Legal staff.

HUMANA

December 2016-October 2017

Special Investigator-Special Investigations Unit

Responsible for managing large caseloads of medical fraud investigations and proactively detecting fraudulent activity. Conduct investigations on complex cases, and collaborate with investigative researchers and other investigative teams to achieve investigative objectives. Develop fraud trend analysis and data analytics. Maintain data tracking systems for suspect activity. Conduct investigative interviews with members, medical providers and medical staff. Compose detailed investigative reports. Build relationships with market teams and effectively communicate and share information as well as identify fraud, waste, and abuse.

THE HARTFORD INSURANCE COMPANY

July 2007-December 2016

West Territory Manager - Special Investigations Unit

Responsible for the direct supervision, and overall performance of the West Territory Special Investigations Unit. Ensure a timely high quality investigative product while fostering a high performance work environment. Establish guidelines and protocols to enhance the SIU Anti-Fraud Program. Duties include the supervision and coordination of investigations, and consultations regarding the overall corporate direction of fraud control. Ensure collaboration and maintaining of relationships with all business partners on a national level while marketing SIU services and educating personnel. Responsible for fraud detection and deterrence, direct supervision of investigators, quality assurance, expense and budget management, managing overtime, collaboration, and working with various business partners and claims offices, while providing fraud awareness training to integral business partners. Interface with the SIU industry, NICB, DOI and Law Enforcement. Highly knowledgeable in appropriate investigative techniques & strategies in all lines of insurance to include; Medical Fraud, Automobile Coverage (including Bodily Injury, Medical Payment, and Auto Theft), Complex Workers’ Compensation, Cargo, Life, Health, Disability, Property, Fires, and Organized Fraud Rings. Extensive experience with the laws pertaining to insurance claims, mandated reporting deadlines, good-faith investigative techniques, and an understanding of emerging issues with a focus on Major Case and Medical Fraud. Coordinate and establish working guidelines with the SIU Forensic Data Analytics team to proactively identify suspect claims and to conduct link analysis on complex medical fraud claims. Responsible for complying with the Department of Insurance Fraud reporting requirements and submitting the annual compliance report.

PROGRESSIVE INSURANCE COMPANY

2003 – 2007

SIU Manager California

Responsibilities included directing the performance of the SIU staff and investigations for

California. Accountable for team results including compliance with SIU Best Practices, quality assurance reviews, performance management, and calibration of files to corporate audit standards. Established and implemented procedures for identifying potentially suspect claims while working closely with claims management for appropriate claims resolution. Responsible for SIU fraud awareness training. Involved with the selecting and managing of appropriate vendors including attorneys, private investigators and forensic experts. Duties included supervising the investigation of organized fraud rings with a focus on medical fraud and suspect injury claims. Extensively involved with organized fraud ring and link analysis investigations.

NATIONWIDE INSURANCE COMPANIES

1991-2003

2000- 2003 SIU Manager California-Allied/Nationwide Insurance, Sacramento, CA

Responsible for the supervision of investigations and all affiliated matters in the state of California. Extensively involved in composing various investigative guidelines policies and procedures for SIU activities including SIU Best Practices, suspect claims identification, reporting protocol and investigative requirements. Established working relationships with local, state and federal government authorities as well as civil authorities on cases suspected of insurance fraud. Responsible for providing a timely, quality investigative product to make appropriate decisions involving fraud issues. Heavily involved in the integration of SIU teams from acquired companies and creating a positive work environment.

1995-2000 SIU Western Zone Manager, Phoenix, AZ. and Anaheim, CA

1991-1995 Senior Supervising Special Investigator-Dallas, Texas

EDUCATION:

Bachelor of Science in Criminal Justice- University of Texas at El Paso

Fraud Claim Law Specialist Designation

INDUSTRY AFFILIATIONS:

National Health Care Anti-Fraud Association

Northern California Fraud Investigator Association

International Association of Special Investigation Units (IASIU)

Insurance Fraud Advisory Board

REFERENCES:

Robert Burcina JD 707-***-****

David McDowell Senior Partner McDowell, Shaw and Garcia 925-***-****

Michael Izuno 323-***-****

Contact this candidate