SUMMARY

Senior-level Insurance Claims Professional with expertise in technical fraud investigation, detection, prevention, and compliance for life, disability, dental, vision and medical claims delivering savings to companies. Comprehensive knowledge of medical terminology, coding and reporting procedures to include: CPT, ICD, HCPC’s, CDT and CMS rules and regulations. Reputation for being a quick study, adaptable, creative and intuitive professional who maintains positive working relationships with internal and external customers. Compliance/Quality Assurance driven with a true passion for root cause analysis and accurate fixes. Certified Fraud Examiner.

Additional competencies include:

Business Acumen

Communications

Training & Mentoring

Claims Analysis

Negotiation

Talent Management

Process Improvement

Contract Review

Complex Investigations

LEWIS CONSULTING 2017 – 2019

Owner, Insurance Claims Auditor/Consultant Kansas City, MO

Private Contractor/Claims Consultant specializing in medical insurance claims audits for Reinsurance carriers, and other Third Party Administrators for a wide variety of insurance products. Identifying control gaps/weaknesses, making recommendations for process improvement to achieve consistent savings.

HIPAA compliant Certified Fraud Examiner.

CONDUENT

2015 -2017

Senior Consultant, Audit and Reporting Services

Conducted stratified and focused client audits for medical, vision, dental and hearing claims at various administrators throughout the United States. These audits focused on the administrators’ compliance with the clients' Summary Plan Document (SPD).

Detected numerous overpaid/underpaid claims, pinpointed key control gaps and made appropriate/applicable recommendations for recovery of funds and implementation of control gap fixes.

LEWIS CONSULTING

Owner, Insurance Claims Auditor/Consultant Kansas City, MO

2014 – 2015

Private Contractor/Claims Consultant specializing in medical insurance claims audits for Reinsurance carriers, and other Third Party Administrators for a wide variety of insurance products. Identifying control gaps/weaknesses, making recommendations for process improvement to achieve consistent savings.

HIPAA compliant Certified Fraud Examiner.

FIDELITY SECURITY LIFE

2007 - 2014

An insurance company specializing in niche products, partnering with various MGA’s and TPA’s throughout the United States.

Corporate Claims Auditor – CFE – SIU, Kansas City, MO

Conducted internal/external audits on a wide variety of insurance claims products; included Life, Health, Dental, Vision, Limited Medical, Long and Short Term Disability, Aggregate/Specific Excess Loss.

HIPAA compliance. Handled fraud examination, SIU (special investigations unit) as concurrence officer.

•Detected and investigated numerous overpaid/underpaid claims involving multi-thousands of dollars. Pinpointed key control gaps and made appropriate/applicable recommendations for recovery of funds and implementation of control gap fixes.

•Identified specific areas of risk through detailed analysis of compliance, underwriting and contractual agreements revealing potential exposure to multi-thousands of dollars in loss.

•Uncovered certain fraudulent activity while in the course of the normal conducting of audits, leading to the identification of the potential of multiple thousands of dollars in loss.

•Investigated fraudulent activity and reported findings with recommendation on course of action.

•Traveled to multiple client partner locations throughout the United States for the purpose of conducting audits.

LEWIS CONSULTING 2000 - 2007

Owner, Insurance Claims Auditor/Consultant Kansas City, MO

Private Contractor/Claims Consultant specializing in Aggregate/Specific Excess Loss claims audits for Reinsurance carriers, and other Third Party Administrators for a wide variety of insurance products. Identified control gaps/weaknesses, making recommendations for process improvement while achieving consistent savings.

•Established and maintained an excellent working relationship with Reinsurance Carriers on blocks of Aggregate and Specific Excess Loss claims contracts.

•Conducted audits of the Aggregate and Specific claims identifying significant savings from several thousands to several millions of dollars.

•Consistently identified control gaps and recommended appropriate fixes.

•Successfully directed the entire operation of business as a working owner/employer.

Prior Experience:

AHRENS FINANCIAL SYSTEMS

Reinsurance Auditor

PRUDENTIAL INSURANCE COMPANY OF AMERICA

Senior Representative

EDUCATION

Hudson Valley College – Troy, NY

Continuing education in Business related studies

University of Maryland – Overseas while serving in the United States Marine Corps

Continuing education in Business related studies

CERTIFICATIONS

Certified Fraud Examiner – The Association of Certified Fraud Examiners

MILITARY

United States Marine Corps – Honorably Discharged Veteran

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