Caryn O'Haire

• Promoted to Senior RN Clinical Auditor in 03/2025 with additional responsibilities including but not limited oversight of additional audit project.
• Responsible for conducting comprehensive review of claim data and /or medical record documentation related to Fraud Waste and Abuse (FWA) investigations opened by the Special Investigations Unit (SIU) from various internal and external sources.
• Work collaboratively with the SIU /FWA Investigator and other internal business areas related to the case, as well as external State/Federal oversight and law enforcement agencies as necessary.
• Liaison and oversight of the pharmacy (PBM) vendor, working closely with both internal and external business areas to ensure regulatory compliance.
• Participates in State (EOHHS) meetings and provides support to management during regulatory audits of federal and state regulators.
• Assist in preparation of documentation for audits, compliance reviews, and regulatory inquiries.
• Oversees the recovery of overpayments identified in SIU investigations.
• Recommend future cost avoidance based on case reviews.
• Utilize computer based data mining tools, claim payment and case management systems to identify aberrant or potentially fraudulent billing patterns.
• Assists management in ensuring policies, procedures, and processes are developed and modified to comply with state regulatory standards.

• Promoted from UM Supervisor to Manager of UM in January of 2019.
• Promoted from Clinical Management Nurse to UM Supervisor in February of 2018.
• Oversight of a team of 10 UM team employees including performance management and coaching of staff.
• Oversight of the utilization management process.
• Compliance to regulatory standards for timeframes of decision making.
• Monitored data trends for utilization & denial rates and created process improvement activities related to this analysis.
• Participated in CMS and NCQA audits.
• Collaborates with Chief Medical Officer (CMO), Associate Medical Director (AMD) and physician reviewers to resolve complex medical review issues.
• Worked on Hospital Acquired Conditions Committee and Utilization Management Committee.

• Performed 72 hour coverage for hospice patients and provided on-site facility and in home end of life services.

Full time unit nurse providing coverage on both medical and surgical floors.