Clenesha Cooks

951-***-**** ad2o8b@r.postjobfree.com Moreno Valley, CA, 92555

Dedicated and highly skilled professional with extensive experience in healthcare operations, fraud case management, and government resource funding. Seeking a challenging position that leverages my expertise in claims adjudication, benefit and eligibility determination, and fraud prevention, while also utilizing my strong analytical and communication skills. Committed to achieving excellence in a dynamic work environment.

EXPERIENCE

Associate Fraud Case Manager 2021-Current Horne LLP, Remote

Analyzed daily caseloads to identify irregularities in funding request applications, ensuring program integrity.

Budgeted and validated eligibility through thorough verification of identity and supporting documents, upholding program integrity.

Initiated and pursued investigations into suspicious activities, promptly completing Fraud Waste and Abuse (FWA) forms.

Scrutinized applicant case files with meticulous attention to detail, uncovering irregularities.

Documented findings with precision to support fraud determinations.

Specialized in disaster and recovery/emergency services, employing sharp investigative skills to detect and counteract fraudulent funding requests, thereby safeguarding public resources.

Conducted exhaustive analyses of government resource approvals, ensuring strict compliance with regulations.

Demonstrated exceptional written communication skills by crafting concise reports and case recommendations.

Tier 2 Sr. Pharmacy Escalations Specialist 2011-2021 United Healthcare/OptumRx, Remote

De-Escalation, first call resolution.

Completed Suspicious Activity Reports for identity theft claims regarding insurance pharmacy (OptumRX) benefits.

Troubleshoot rejections on claim adjudications.

Managed benefit coverage by initiating Prior authorizations, as well as appeals and Escalated appeals.

Expert with UMR, CalPers, Kaiser, Unions, Medicare/Medicaid. Worked with plans to determine cause and effect with a 24-hour turnaround time.

SKILLS

Benefit and Eligibility Determination, Fraud Case Management, Government Resource Funding, Data Analysis and Reporting, Investigative Skills, Budget Management Regulatory Compliance, Clear and Concise Writing, Team Leadership Proficiency in Microsoft Word and Excel, Time management, Quick learner, Ability to delegate, Adaptable. Intermediate experience with Power BI/SpeedChain, Data Tree, Oracle, IRIS, AS400, Investigations/Interviewing, Navigator, Linux/Lexus Nexis, Excel, Word processor, Outlook, Teams, Jabber, Smart Sheet, JIRA, ShareFile, Bill.com, HIPAA, PII, Medical/Pharmacy Terminology, PBM, Salesforce, SharePoint, IBM, CRM, CMS, Case management, fraud detection and mitigation, case analysis, Healthcare (Benefits, eligibility, claim adjudication) and QA/QC

EDUCATION

Bachelor, Criminal Justice 09/2023

Strayer University

Masters, Forensic Psychology Current-2025

Grand Canyon University

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