MARCELINO RODRIGUEZ, CFE

**** ******* ******, *********, ** 32955 • 305-***-**** • advrfq@r.postjobfree.com

EXPERIENCED SIU INVESTIGATOR

SIU Investigator • SIU Field Investigator • FWA Investigator

Fraud Investigations • Healthcare Fraud • Code of Conduct • Compliance issues.

Led Investigations • Reported Misconduct • Facilitated Disciplinary Actions • Conducted Interviews

Identified $12M in Overpayments • Analyzed Claims • Led Recoveries • Reported Abuse

WORK EXPERIENCE

Health Alliance Plan, Troy, MI Oct 2020 – Oct 2021

SIU Investigator

●Led investigations in Fraud, Waste, Abuse (FWA), and matters that involve risk and compliance.

●Analyzed possible incidents of FWA in all lines of business through data analysis.

●Clarified complaints for further investigations or referrals to appropriate departments by interviewing complainants that reported events using the hotline or other means.

●Collaborated with medical directors, lawyers, and other internal department officials to discuss findings and make determinations about the status of providers filing aberrant claims.

●Prepared reports of interviews, contacts, and investigations, and issued letters requesting reimbursement for inappropriate claims.

●Interviewed providers and contractors to determine evidence of FWA.

Jackson Health Plan March 2013 - March 2014

Healthcare Fraud, Waste and Abuse Officer/SIU

●Directed FWA and SIU activities involving all lines of business including Medicare Part C, Part D, Medicaid, and Commercial Insurance.

●Reported incidents of FWA and implemented a strategy to detect and prevent FWA by serving as a member of the Executive Compliance Committee.

●Prepared reports on Suspected/Confirmed instances of Fraud and Abuse, Quarterly Fraud and Abuse Reports. (QFAAR) and Annual reports.

●Conducted investigations based on allegations of services not rendered, duplicate billing and medical necessity issues Investigated issues dealing with unlicensed individuals.

Catapult Consultants, Arlington, VA July 2012 - Feb 2013

Investigator

●Spearheaded investigations of fraud, waste, and abuse in the area of Medicare and Medicaid.

●Performed investigations, audits, evaluations, and inspections regarding the delivery of and payment for health care services.

●Implemented the civil, criminal, and administrative statutes applicable to health care.

●Provided industry assistance, including suggested opinions, safe harbors, and specific fraud alerts regarding fraudulent health care practices.

●Prepared Reports of Investigations detailing material and relevant evidence.

●Conducted joint investigations with federal and state law enforcement agents.

●Presented reports to Senior Managers and Directors as well as to state and federal prosecutors.

●Issued letters requesting reimbursements for inappropriate claims.

●Analyzed data and perform on-site reviews of medical records.

Magellan Health, Miami, FL Dec 2011 - July 2012

Investigator

●Championed investigations dealing with fraud, waste, and abuse in mental healthcare sponsored by state Medicaid programs and private insurance carriers.

●Analyzed claims and medical records to determine the appropriateness of claims and submitted reimbursement requests for overpayments.

Office of the Attorney General, State of Florida March 2011 - Dec 2011

Investigator

●Prepared investigative files for Special Counsel and Assistant Attorney General to engage in negotiations with entities violating security breach statutes or fraudulent/deceptive practices.

●Assisted Special Counsel in matters of multi-state investigations affecting consumers.

Humana, Miramar, FL Dec 2008 - March 2011

Manager, Special Investigations Unit

●Oversaw 18 Investigators and Supervisory investigators while overseeing SIU operations.

●Delivered determinations as to de-participating providers for inappropriate billing practices.

●Issued disciplinary memorandums to employees not complying with standards including termination from employment. Interview applicants and recommended hiring.

Healthcare FWA, SafeGuard Services, Miramar, FL Feb 2007 - Dec 2008

Program Integrity Contractor

●Made determinations about inappropriate claims and issued letters collecting overpayment.

●Issued letters placing providers on pre-payment actions and issued de-participating letters to providers as a result of inappropriate billings.

●Prepared documents for RFIs and assisted law enforcement with the prosecution of providers.

Prior Experiences: US Secret Service, Special Agent, Special Agent, OIG, US Department of Labor, Criminal Investigator; US Army, Finance Operations Sergeant Major, Senior Advisor

EDUCATION

Catholic University of Puerto Rico, Ponce, Puerto Rico

Bachelor of Business Administration

TECHNOLOGIES, CERTIFICATIONS, AWARDS, PROFESSIONAL DEVELOPMENT, AFFILIATIONS, & LANGUAGES

Technologies: Microsoft, Excel, Word, Business Object, Cognos

Certifications: Certified Fraud Examiner

Awards: Awarded a Bronze Star during hostilities with IRAQ

Professional Development: Healthcare Fraud Investigations, Provider Fraud Investigation, Beneficiary Fraud Investigations, Broker Fraud Investigations, Employee Integrity Investigations, White Collar Crime Investigations, Contract Fraud, Rules of Evidence, Conflict of Interest, CPT and ICD Training, Graduate from the U.S. Treasury Law Enforcement Agent School & U.S. Secret Service Law Enforcement Agent School.

Affiliations: Member of the NHCAA

Languages: English, Spanish

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