Special Investigator of medical insurance fraud

Charles (Denny) Mudd

**** ********** ***** #10-502-***-****

Louisville, Ky. 40220 ********@***.***

OBJECTIVE: To obtain a position that will use my analytical, communication, and problem solving skills to contribute to the organization’s success.

WORK HISTORY:

8/18 – 9/18 Adecco

Provided logistic support to agents across the country to insure orders are received and sent accurately while working a temporary assignment at GE Appliances

7/17 – 6/18 Carney Carpet Gallery

Sold carpet, vinyl, hardwood and laminate floors to residential and commercial customers. I am directly involved in the process through working with the customer in the store, measuring on site, scheduling, preparing the installers for the job and any necessary follow-up during and after the installation.

Previously sold floors for 3 years at Sam Kinnaird Flooring prior to Humana

4/17 – 5/17 Walgreens

Was trained to work most roles (pharmacy, cashier, photography, etc)

Near the end of May, I was to be a pharmacy technician. However, the person I was supposed to replace decided to stay at Walgreens.

1/03 – 4/16 Humana, Inc.

Frontline Leader, Service Fund 10/14 – 4/16

Provided guidance and leadership to associates and served as a mentor for their day-to-day activities

Identified reasons for variation in individual performance and took appropriate actions that resulted in improved performance

Co-ordinated meetings with Service Fund, Finance and the markets to ensure contracts were loaded correctly

Helped lead the first summit between the Louisville Service Fund Teams in San Antonio with the market offices. This was a very successful meeting resulting in increased communication, productivity and accuracy.

Team Lead, Special Investigations Unit 10/13 – 10/14

Held market meetings with the providers, clinical review, and management when a provider consistently billed incorrectly

Addressed learning opportunities when associates are struggling with concepts, ideas or practices

Performed case reviews with team members to determine status and next steps

Special Investigator, Special Investigations Unit 5/11 – 10/13

Detected and investigated potential health insurance fraud by reviewing medical records, claims, phone interviews and referrals with a clinical review team

Reported suspected fraud, waste and abuse to the Department of Insurance, CMS, other insurance carriers and law enforcement

Facilitated meetings and built strong relationships between SIU leadership, Clinical Reviewers, Legal Counsel, Market, and Quality Teams

Project Analyst, Senior Product Design 1/08 – 5/11

Correctly filed plans for the Mid-South Region by compiling data from actuaries, market offices, and Product Design management into all the appropriate systems, running automated quality checks, and uploaded plans to HPMS

Analyzed competitor data including cost shares for Medicare covered services, membership, service area, supplemental services, and value added services

Worked with Strategic Communications to ensure correct Summary of Benefits and Annual Notifications of Changes were published for Medicare members

Trained associates on Senior Product Systems with great reviews on the trainings

Assumed a lead role in the Peoria acquisition by working with Implementation and the acquired company to ensure a smooth transition of members

Maximus Federal Services Specialist Grievance and Appeals 12/05 – 1/08

Researched all cases involving a decision of dismissal, partial overturn, and uphold

Submitted the complete and appropriate documents to Maximus (CMS)

Answered additional information requests, recorded the final determination and effectuated any overturns from Maximus

Grievance and Appeals Specialist 8/04 – 12/05

Investigated all appeals and grievances from Humana Medicare members and providers before providing a decision regarding the outcome

Met quality expectations with 95% accuracy on CMS compliance standards

Met deadlines and compliance for acknowledgement and determination letters

TECHNICAL SKILLS:

Microsoft: Excel, Word, PowerPoint, SharePoint

Additional: Metavance, CI, Legacy, Oracle, CMS systems

Medical billing knowledge: all lines of business with a strong focus on managed care including Medicare Advantage and Medicaid, HCPCS/CPT coding, ICD 9 coding, and 1500 forms.

EDUCATION:

University of Louisville

Bachelor of Arts in Psychology - May 1994 (Eagle Scout Full Scholarship)

University of Louisville

Kent School for Social Work - 1995-1998 (chose not to continue this line of work)

ACTIVITIES and LEADERSHIP:

President of Savannah Row Condominium Association, 2007, 2016

Vice President of Savannah Row Condominium Association, 2008

Middle School Basketball Coach, 1992-2003

Assistant Scout Master, 1990-2001

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