Field Adjuster/Fraud Investigator

Gaston M. Boada, CFE

**** ******* **** ***** #***

(561) 716- 5294

Boynton Beach, FL 33437 *******@*****.***

Field Claims Adjuster

PROFILE:

 Superior investigative, communicative and organizational skills. Experienced in handling confidential material.

 Experienced in subrogation claims/third party recovery and following reclaim procedures.

 The capability of working independently or as a team to gather/analyze information and determine the course of action.

 Able to conduct/coordinate research and in-depth investigations; interview witnesses, document statements and examine the physical conditions present

 Effective interpersonal skills and the ability of dealing with internal and external sources, at all levels. Able to speak, read and write fluent Spanish. 520 All-Lines Licensed Claims Adjuster/Certified Fraud Examiner.

EXPERIENCE:

Safeguard Services, LLC, Miramar, FL

Fraud Investigator April 2005 - Present

Responsibilities include, using advanced data analysis techniques to plan, organize and conduct investigations of alleged or suspected Medicare fraud and abuse. Proactively seeks and develops leads from a variety of sources including government and private agencies. Compiles and analyzes complex data (financial statements, claims, reports, policies, etc.) and audits accounts to detect potential fraudulent or abusive practices or vulnerabilities. Thoroughly documents findings and conclusions and prepares comprehensive investigation referrals reports with recommended actions to government office/entity, law enforcement and/or prosecutors.

 Perform in-depth interviews with physicians, staff and beneficiaries to determine if fraudulent or aberrant medical billing procedures to Medicare are in existence.

 Develops and prepares potential fraud alerts.

 Experienced in undercover activity checks.

 Renders expert testimony in judicial proceedings

Broadspire, Plantation, FL.

Long Term Disability Claims Examiner II March 2004 – April 2005

Responsible for evaluating, interpreting and making decisions using relevant medical information such as treatment/consultation reports, diagnostic and functional capacity evaluations to assist with claims processing on moderate-to-difficult long term disability claims. Examine medical information with medical and nursing staff to determine pre-existing conditions.

 Coordinated and facilitated Social Security Disability application process to reduce employer exposure.

 Analyzed claim activity and prepared reports for clients, carriers and management.

Medi-Trans, Inc., Pompano Beach, FL

Medical Collection Specialist

September 2002 – January2004

Responsible for the collection and maintenance of all past due accounts receivables. The services and products offered by Medi-Trans, Inc., are transportation, translations and durable medical equipment.

 Superior negotiation skills to reach repayment agreements with responsible parties.

Liberty Mutual Insurance Group, Ft. Lauderdale, FL. Senior Claims Representative July 2001 – September 2002

Responsible for investigating, negotiating the settlement of property and casualty automobile claims. Worked with in-house and claimants’ attorneys in the settlement of property damage claims. Settled claims promptly by issuing company drafts in payments for claims within authority.

 Experience working in a fully automated environment documenting all findings and activities on each case.

 Interpreted and made decisions using independent judgment on moderate to difficult claims and policy coverage and determined if it applied to claims submitted.

Claim Technologies, Inc., Plantation, FL

Subrogation Manager January 1993 – July 2001

Responsible for all aspects of the recovery of all subrogation claims for this independent adjustor. Handled subrogation claims for multiple insurance carriers. Managed a multi-state territory that included Florida, New York, New Jersey, Maryland, Pennsylvania and Texas.

 Filed claims against responsible parties; negotiate repayment plans and initiated legal proceedings when necessary.

 Represented the carriers in mediations and trials; worked with attorneys in the settlement of property damage claims.

EDUCATION:

Kean College of New Jersey, Union, NJ

Completed two years of course work.

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