Healthcare regulatory subject matter expert

Amy Sellers, AHFI, CSPO

***************@*****.*** https://www.linkedin.com/in/amy-sellers-ahf

c. 812-***-****

KEY STRENGTHS

Complex Fraud Investigations Policy Drafting Change Implementation Process Improvement Sample Methodology Compliance Audits Stakeholder Communication Business Development Partnerships Data Analysis Data Interpretation Product Owner Scrum Agile Machine Learning Cloud Data Warehousing Scrum Master Tableau CSPO Jira Cross-Functional Teams Negotiations CMS HHS/OIG Medicare Medicaid PBM CAREER OVERVIEW

Oscar Health Tempe, AZ (Remote) 7/2024 - present

Investigations Lead, SIU (Management)

Managed four SIU Investigators and Analysts, including hiring and onboarding Led process improvement initiatives to reduce case resolution time and enhance accuracy Directed complex investigations, conducting data analysis, analyzing audit reports, providing case direction

Implemented case stage approval process improving workflow and case monitoring metrics Championed a comprehensive sample selection methodology to maximize overpayment calculations and streamline investigative processes

Worked cross functionally with internal audit teams to schedule, produce and interpret best results Worked closely with leadership to ensure all policies aligned with regulatory standards and industry best practices

Conducted comprehensive audits of existing processes, identifying opportunities for improvement and communicated to Leadership

Managed vendor oversight for Compliance and Investigations Departments Handled provider disputes and negotiated overpayment settlements Developed new audit tool for coding audit team and investigations General Dynamics IT, Healthcare Fraud Prevention Partnership (HFPP), CMS Contract Partner Engagement Specialist Falls Church, VA (Remote) 4/2023 – 5/2024 Managed 45 partner accounts (Medicare, Medicaid, Commercial) resulting in: 25% Increase in partner engagement over one year

15% Recruitment over one year

15% Increase in data sharing over one year

Identified collaboration opportunities between partners and lead monthly Focus Groups Worked with GDIT’s and partners’ Legal Teams to execute Data Sharing Agreements (DSA) Successfully negotiated 30% of the team’s DSAs in fiscal year Negotiated 100% of partners to sign DSAs with no red-lines Collaborated with ETL (Extract Transform Load) Team to move data into data warehouse Worked with new and existing data sharing partners to implement cloud sharing Met modernization goal by signing first two partners into the partnership as cloud sharing Leveraged cloud implementation to reach partners’ modernization goals Demoed individualized Study Results monthly

Provided live and recorded demonstrations of Tableau for review of Study Results Supported virtual and in-person events

UnitedHealthcare Minnetonka, MN (Remote) 8/2019 – 4/2023 Special Investigations Unit (SIU), Manager (Management 4 years) Amy Sellers, AHFI, CSPO

***************@*****.*** https://www.linkedin.com/in/amy-sellers-ahf c. 812-***-****

Directed a team of six investigating organized crime in pharmacy network (enhanced credentialing) Directed a team of eight investigating Medicare Advantage, Medicaid and Commercial medical claims Presented at regular meetings with CMS related to contract compliance Responded to state and federal agencies’ audits and requests for information (RFI) resulting in renewal of contracts

Developed policies and procedures related to state and federal compliance Presented audit findings to key stakeholders in five Medicaid contracted states annually Presented investigative findings quarterly to States and CMS in virtual and in-person settings Managed contractual reporting to 200+ state and federal agencies Tracked compliance for team case load of 240+ complex fraud investigations Improved team effectiveness in meeting contractual requirements by 45% Implemented, trained and monitored new policies and change process in response to team effectiveness Drafted templates and user guides; provided trainings and monitored effectiveness Worked cross functionally with internal audit teams to schedule, produce and interpret best results Handled provider dispute escalations and negotiated overpayment settlements Supported the development of newly acquired team resulting in 100% SIU growth Accountable for hiring, reviews and promotions of investigators Qlarant, I-MEDIC, CMS Contract Easton, MD (Remote) 3/2018 - 8/2019 Medicare Fraud Investigator

Developed criminal investigations for Medicare Part C and D claims Conducted data analysis on Prescription Drug Events (PDE) and Medicare Advantage claims Presented investigative findings at CMS/HHS/OIG Major Case Coordination Meetings monthly Mentored new investigators

Ivy Tech Community College Evansville IN, 8/2013 – 5/2017 Adjunct Professor

Corrections CRIM 130

Criminal Investigations CRIM 113

Ethics in Criminal Justice CRIM 201

Amy Sellers Investigations and Consulting Evansville IN, 5/2013 - 3/2018 Owner, Consultant, Licensed Private Investigator (Management 5 years) Consulted on whistleblower cases for presentation to the government with 100% acceptance Conducted state and federal healthcare regulations research for private law firms Wrote expert opinions for healthcare fraud defense cases Specialized in physical and remote surveillance, witness interviews, audits of medical, bank, government, insurance, and pharmacy tracking records

Employed/sub-contracted six investigators

Indiana Attorney General’s Office, Medicaid Fraud Control Unit Evansville IN, 6/2002 – 5/2013 Investigator, Federal Healthcare Task Force (Interim manager 1 year) Lead joint state and federal investigations in healthcare provider fraud and white-collar crime Strong understanding of stakeholders’ priorities resulted in 90% case acceptance rate by state and federal prosecutors

Testified in state and federal trials resulting in convictions for 100% of cases Amy Sellers, AHFI, CSPO

***************@*****.*** https://www.linkedin.com/in/amy-sellers-ahf c. 812-***-****

EDUCATION

University of Evansville

Bachelor of Science Sociology and Criminal Justice ACHIEVEMENTS

Accredited Healthcare Fraud Investigator (AHFI), National Healthcare Anti-Fraud Association (NHCAA) Speaker - NHCAA Training Conference, New Orleans, 2015 Certified Scrum Product Owner (CSPO) - Project Management (Agile Framework) Certified Scrum Master - Project Management (Agile Framework) HHS/OIG Integrity Award Recipient, 2009

Yoga Instructor

Boston Marathon

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