Customer Service Management
Resume:
Adahzell T. McMillan
Baltimore, MD
443-***-**** ******@*******.***
Summary of Qualifications
Accomplished health insurance professional with 10+ years of experience in the industry investigating fraud, waste and abuse through analyzing data, allowable fees, benefit plan limitations, state and federal regulations.
Area of Expertise
Organization Analyzing Data State/Federal regulations
Fee Schedules Plan benefits Identify payment errors
Internal controls Policy implementation Interviewing
Reporting Claims auditing Time management
ACCOMPLISHMENTS
Assigned and reduced the state specific backlog by revising reporting methods to eliminate unnecessary reporting.
Revised forms and documents to make the follow-up process quicker and allegation based.
Substantial amount of charges identified for recoupment.
Set-up departmental reference library – Manual (Coding, Procedural, Profession specific and Diagnostic), periodicals, resource books and seminar related documentation.
EMPLOYMENT HISTORY
SIU Investigator 1996 - 2015
Magellan Health, Incorporated Columbia, MD
Investigated allegations of possible fraud, waste and abuse presented via hotline calls, internal and external department referrals, government agencies, members, data mining, claims trends, and news articles.
Provide support to the SIU to achieve production and case goals.
Prepared reports identifying evidence to support the allegations, areas of concern in payable charging errors, benefit plan waste, provider procedures errors, identified recovery dollars, and inappropriate plan, state and federal guidelines abuse.
Train in the update procedures, coding and techniques used by fraudsters through educational webinars, conferences and seminars – ACFE, NHCAA, Lexis-Nexis, and Magellan Achieve.
File and maintain electronic weekly management case log.
Logged and maintained all case files through regular entry into the reporting application. Application is able to monitor case activity, duration, documentation, identified recovery charges, payments, phone calls, surveys, and interviews.
Utilize provider identification markers to run and analyze claims billing reports.
Assist in the formulation of action plans.
Refer providers to licensing boards, state regulatory entities, and internal departments for additional handling with recommendations and evidential report summary.
ADDITIONAL RELEVANT EXPERIENCE
Magellan Health Columbia, MD
Claims Processor
Claims Specialist
Senor Claims Specialist
Auditor/Underwriter
Benefit Implementation Specialist
SIU Investigator
TRANSFERRABLE SKILL SET
Microsoft Office Microsoft Word Excel
Power Point Online Faxing NetMeeting (online conference)
Lexis-Nexis NHCAA SIRIS CLEAR
Outlook Access Multiple line Phones
Online faxing Fax machine Calculator
Time Management Customer Service Training
Client Relations Program Modifications Administrative Support
Claim Systems – AS400, AMYSIS, CATS, CAPS, STARS, NASCO, CURE, QUEST
EDUCATION & PROFESSIONAL DEVELOPMENTS
Coppin State University Special Education/Psychology Baltimore, MD
Edmondson High School General Business Baltimore, MD
CERTIFICATION/PROFESSIONAL DEVELOPMENT
AHFI-Accredited Healthcare Fraud Investigator 2011 - Present
NHCAA – National Health Care Anti-Fraud Association
Board Member Maryland ACFE 2009 - 2015
ACFE- Association of Certified Fraud Examiners
American Heart Association 2014 – 2016
Heartsaver CPR AED
REFERENCES
Pamela Leonard
Manager - DHMH – State of Maryland
******.*******@********.***
Hillary Waller
Account Executive – Magellan Health, Inc.
********@**************.***
John Grimes, III
Retired, Past President Maryland ACFE Chapter 21
*************@***.***
Bunny Greenhouse
Retired, Pentagon Federal Contracts and Procurement
*******@***.***
Charles B. Owens
President, Baltimore City Chamber
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