Christian Bankes
Odessa,United States
Summary
Experienced and self-motivated professional with twelve years of expertise in the insurance industry, including prior supervisory experience. Specialized in investigating insurance fraud and proficient in data analysis and management. Known for delivering significant cost savings and facilitating successful legal prosecution of fraudulent parties, resulting in over $500,000 in savings for employers. A versatile team player who excels both independently and in collaborative environments, consistently delivering excellent results
Overview
13
13
years of professional experience
1
1
Certification
Work History
Senior Analyst, SIU Investigator
Oscar Health Insurance
Tampa , United States
2023.09 - 2024.08
- Conducted comprehensive investigations of potential fraud waste, and abuse, within individual health plans obtained through the Health Insurance Marketplace on medical providers and medical care facilities
- Uncovered and documented irregularities, including improper coding, insufficient treatment records, and services that were not provided
- Developed and executed SQL queries to retrieve provider data from health plan databases, conducting comprehensive analysis to detect anomalies in medical records and billing practices
- Lead process development and investigations of brokers and agents
- Resulting in over 15 brokers terminated from the plan and 2 prosecuted
- Lead process development and investigations of members and possible ID theft, leading to over $70,000 paid claims recovered
- Development of member interview process for medical provider investigations
- Coordinated with state and federal law enforcement agencies by submitting fraud referrals as needed and actively supported ongoing investigations led by the authorities
- Secured over $300,000 in reimbursements for the health plan through effective investigative efforts.
SIU Specialist
American Integrity Insurance
Tampa , United States
2021.11 - 2023.09
- Conducted thorough investigations of fraud referrals received by the Special Investigations Unit (SIU)
- Utilized private investigative tools to gather public and non-public information, including open-source intelligence, to assess the history of the property and insured individuals
- Reviewed and analyzed proof of damages obtained during investigations, interviewing policyholders based on gathered information
- Managed a comprehensive database to store and analyze investigative data, enabling the identification of fraud trends
- Led a project to develop an updated predictive fraud model, implementing a streamlined and color-coded warning system based on data history and analysis
- Executed SQL queries to generate daily reports of claims requiring review based on the developed fraud model, distributing the reports to the fraud department and management
- Collaborated with local and state law enforcement agencies, referring relevant investigation files for possible legal action
- Contributed to the arrest and prosecution of 5 individuals involved in fraudulent activities, resulting in an estimated $350,000 in saved settlements for the company.
SIU Investigator
Centene
Tampa , United States
2020.12 - 2021.11
- Conducted comprehensive investigations of potential waste, abuse, and fraud within Medicaid, Medicare, and commercial health plans involving medical providers and medical care facilities
- Utilized SQL queries to extract provider records from health plan databases, performing detailed analysis of the data to identify aberrations in medical records and billing practices
- Identified and documented aberrations, including improper coding, inadequate treatment notes, and instances of services not rendered
- Prepared comprehensive reports outlining investigation findings, including the amount of over-payment by providers or facilities
- Developed data visualizations using Microstrategy as part of the report
- Facilitated reimbursement processes by submitting approved reports to health plans and requesting reimbursement from providers or facilities
- Collaborated with state law enforcement agencies by submitting fraud referrals when necessary, cooperating with any subsequent investigations conducted by the authorities
- Achieved over $200,000 in reimbursements for the health plan through successful investigations
- Contributed to the suspension of two medical providers from the health plan and the arrest of one individual for fraudulent activities.
SIU Investigator I
The General Insurance
Tampa , United States
2016.07 - 2020.07
- Review any fraud referrals for possible investigation
- Holistically review policy and Insured's prior claim history
- Use company based resources as well as public resources to obtain more background information on parties in the claim
- Contact all parties involved in the claim and take recorded statements with them in regards to the loss
- Contact other possible third parties such as law enforcement, tow companies, or witnesses and take statements
- Review damages and check for signs of prior damages or staged damage
- Request and review records from insured's such as bank, phone, tax, or residency documents for possible links
- Review medical records and treatment bills in comparison with the loss details and mechanism of injury
- Run data reports on medical providers using prior claims
- Work with the claims department throughout the investigation and request any documents that need to be sent to the insured
- Upon closing of investigation report findings to the claims department and, as needed, refer file to the National Insurance Crime Bureau and Department of Insurance based on the policy state
- Cooperate with the Department of Insurance on their investigation.
PIP Adjuster/SIU Liason
Direct General Insurance
Dallas , United States
2015.02 - 2016.06
- Investigate claims made for Personal Injury Protection
- Explain PIP coverage to injured parties or their attorneys
- Explain the state laws to injured parties pertaining to PIP coverage or attorneys
- Confirm coverage with medical providers
- Review treatment to make sure it is in line with injuries to the party claiming benefits
- Adjust high-level claims involving the Special Investigations Unit for potential fraud
- Participate in all Special Investigation Unit meetings and briefings
- Work with the Special Investigation Unit on medical providers of interest and pre-text policies
- Review all medical notes sent in for injured parties and make sure CPT/ICD codes are in line for treatment provided
- Handled PIP claims for losses in FL and TX.
PIP Adjuster I
Esurance
Tampa , United States
2013.08 - 2015.02
- Investigate claims made for Personal Injury Protection
- Explain PIP coverage to injured parties or their attorneys
- Explain the state laws to injured parties pertaining to PIP coverage or attorneys
- Confirm coverage with medical providers
- Review treatment to make sure it is in line with injuries to the party claiming benefits
- Review all medical notes sent in for injured parties and make sure CPT/ICD codes are in line for treatment provided
- Handled PIP claims for losses in FL, MN, KY, MD, and seven Med Pay states.
Claims Adjuster Coach
Esurance
Tampa , United States
2011.10 - 2013.08
- Investigate claims made for automobile damages
- Determine who was liable in automobile accidents
- Explain coverage to policyholders
- Work with repair shops and appraisers on damage estimates
- Assist policyholders with vehicle repairs
- Assist the Express claims adjusters with any questions they had on claims
- Audit claims in the Express Claims department
- Manage the Express Claims department when management was away.
Education
GED -
Nova Southeastern
Davie, FLSkills
- Claims Management
- Policy and Coverage Analysis
- Fraud Detection
- Superior Communication Skills
- Technical Proficiency (Excel, SQL, Tableau, etc.)
- Analytical Thinking
- Detail-Oriented and Organized
- Ability to Work Remotely and Independently
- Attention to Detail
Certification
- Google- Data Analytics
- University of South Florida- Business Analytics
- ADJUSTER - ALL LINES (0620), Florida
Designations
Fraud Claims Law Associate (FCLA)
Designations
- Fraud Claims Law Associate (FCLA)
Timeline
Senior Analyst, SIU Investigator
Oscar Health Insurance
2023.09 - 2024.08
SIU Specialist
American Integrity Insurance
2021.11 - 2023.09
SIU Investigator
Centene
2020.12 - 2021.11
SIU Investigator I
The General Insurance
2016.07 - 2020.07
PIP Adjuster/SIU Liason
Direct General Insurance
2015.02 - 2016.06
PIP Adjuster I
Esurance
2013.08 - 2015.02
Claims Adjuster Coach
Esurance
2011.10 - 2013.08
- Google- Data Analytics
- University of South Florida- Business Analytics
- ADJUSTER - ALL LINES (0620), Florida
GED -
Nova Southeastern
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