Summary
Overview
Work History
Education
Skills
Certification
Additional Information
Timeline
David A. Duhaime

David A. Duhaime

Carrollton,TX

Summary

Motivated professional with experience in investigations, project and contract management, product development and successfully increasing operational effectiveness by building relationships and setting clear goals. Strong communication and interpersonal skills for providing superior operational performance and increased ROI.

Overview

24
24
years of professional experience
1
1
Certification

Work History

Regional Account Manager

THOMSON REUTERS
03.2020 - Current
  • Pondera was acquired by, in 2020
  • Increased sales with execution of full sales cycle processing from initial lead processing through conversion and closing.
  • Subject Matter Expert (SME) and assist with product design and development of suite of Fraud Waste and Abuse solutions.
  • Met with customers to discuss and ascertain needs, tailor solutions and close deals
  • Promoted conversion of casual shoppers into customers through product knowledge and product solutions to meet customer needs
  • Achieved or exceeded company-defined sales quotas

Account Executive

PONDERA SOLUTIONS
10.2018 - 03.2020
  • Responsible for business development of existing accounts while proactively pursuing new accounts with focus on Managed Care, Medicare and Medicaid.
  • Leveraged Pondera Solutions' suite of Fraud, Waste, Abuse (FWA), analytics solution and other technology and innovation to tailor solutions for common account problems
  • Employed proactive and collaborative approaches to strengthen relationships and manage customer needs.
  • Served as a SME in development of products of services designed to identify and deter FWA

Director

ANTHEM BLUE CROSS AND BLUE SHIELD, Special Investigations Unit
08.2017 - 09.2018
  • Lead operational and P&L responsibility for 23 states of Medicare Managed Care and five Medicaid Managed Care health plan contracts
  • Utilize proactive data analysis to identify potential vulnerabilities for fraud and abuse of medical providers as well as beneficiary eligibility
  • Managed daily operations while overseeing multiple locations to foster increased productivity.
  • Exceeded department goals for recoveries by 60%
  • Oversaw operations and provided corrective feedback to achieve daily and long-term goals
  • Conducted meetings with staff to discuss production progress and to attain production objectives

Principal Consultant

HIGHMARK HEALTH SOLUTIONS
10.2016 - 08.2017
  • Operations
  • Operational and P&L responsibility of a $94 million project reporting to the VP of Government Markets and management of a team responsible for the implementation of a proprietary claims payment platform for Medicaid
  • Collaborated with client and coordination across internal departments to ensure all aspects of the requirements were captured for customer and state compliance.

Vice President of Operations

NCI/ADVANCEMED
08.2015 - 10.2016
  • Zone Program Integrity Contractor (ZPIC) Operations
  • Spearheaded operations and maintain P&L responsibility for $84M+ in contracts with oversight of 400+ associates and contractors across 34 states, to identify Fraud, Waste and Abuse (FWA) in Medicare and Medicaid
  • Oversaw contract operations and review processes to identify opportunities to improve outcomes
  • Prepared detailed monthly reports on operational status
  • Prepared annual budgets with controls to prevent overages.
  • Instituted metrics to quantify success of existing operational processes and contract performance
  • Supported Executive Team in reviewing, identifying and prioritizing strategic initiatives
  • Earned recognition from management for executing strategies that resulted in improved ROI across multiple contracts by over 250% within less than one year.

Sr. Vice President of Operations-Program Director

ZPIC
07.2009 - 08.2015
  • Maintained operational and P&L responsibility for an annual contract of $19.6M
  • Provided oversight to 135 associates, including subcontractors dispersed across four states; Texas, Oklahoma, Colorado and New Mexico, charged with identifying FWA in Medicare and Medicaid
  • Supervised a team of management and program integrity professionals
  • Contract included program integrity efforts to identify potential FWA by medical providers and eligibility verification for Medicare and Medicaid recipients
  • Prepared comprehensive reports for CMS and the board of directors providing program status insight at board meetings
  • Drove Program Integrity efforts for CMS’s ZPIC Zone 4 to successfully recover and save $1.9B+ in Medicare and Medicaid dollars where Fraud, Waste and Abuse were suspected
  • Testified in multiple trials, all attaining successful convictions and restitutions ordered of $200M+
  • Consistently achieved progressively improved contractor performance evaluation scores and return on investment.

Vice President of Operations- Director of Medi Medi Program

HEALTH INTEGRITY, LLC, ZPIC
10.2008 - 07.2009
  • Managed $3.8M CMS contract with 27 associates
  • Led workload transition from multiple outgoing contractors and implementation of new contract
  • Created business proposals from Statement of Work (SOW) requirements and established charters for state programs
  • Contributed to development of in-house products and worked with vendors to optimize ZPIC capabilities
  • Delivered quality training while serving as a subject matter expert to outside agencies, including FBI, Office of Inspector General, and state Medicaid Fraud Control Units
  • Directed execution of proprietary program integrity solution to identify FWA
  • Successfully implemented Medicare and Medicaid matching program (Medi Medi) in Oklahoma and Colorado.

Manager, Special Investigator

TRICENTURION
03.2005 - 10.2008
  • Integrated Benefit Management Team (IBMT)
  • Spearheaded comprehensive investigations of doctors suspected of submitting fraudulent claims or developing schemes to defraud Medicare Trust Fund in multiple states
  • Provided leadership and guidance to team comprised of 77 investigators, fraud/data analysts, and clinicians
  • Managed staff development and maintained corporate compliance with applicable internal policies and government regulated contracts
  • Collaborated with senior management on proposals
  • Selected to work on contract under Corrective Action Plan (CAP) by CMS; hired and trained new staff and increased overall production by 300%
  • Contract produced more results in nine months than achieved during first four years of operations

Investigator, Medicaid Fraud Control Unit

New York State Attorney General
08.1999 - 09.2003
  • Charged with Investigating FWA in the state Medicaid Program
  • Testified in court during grand jury proceedings and trials.
  • Conducted interviews with witnesses and clients.

Education

Master of Business Administration -

Jack Welch Management Institute At Strayer University, Dallas, TX
06.2019

Bachelor of Arts - Criminal Justice Studies

Norwich University, Military College of Vermont, Northfield, VT
03.1990

Skills

  • SOFTWARE PROFICIENCY
  • Microsoft Office (Excel, Access, PowerPoint) and computer forensics software
  • Public Speaking
  • Effective Customer Communication
  • Contract Management

Certification

Certified Fraud Examiner, CFE Court certified expert in fraud investigations Graduated with the highest scholastic average from the New York State Attorney General’s Basic Police Academy

Additional Information

  • FBI , Director Excellence Award

Timeline

Regional Account Manager - THOMSON REUTERS
03.2020 - Current
Account Executive - PONDERA SOLUTIONS
10.2018 - 03.2020
Director - ANTHEM BLUE CROSS AND BLUE SHIELD, Special Investigations Unit
08.2017 - 09.2018
Principal Consultant - HIGHMARK HEALTH SOLUTIONS
10.2016 - 08.2017
Vice President of Operations - NCI/ADVANCEMED
08.2015 - 10.2016
Sr. Vice President of Operations-Program Director - ZPIC
07.2009 - 08.2015
Vice President of Operations- Director of Medi Medi Program - HEALTH INTEGRITY, LLC, ZPIC
10.2008 - 07.2009
Manager, Special Investigator - TRICENTURION
03.2005 - 10.2008
Investigator, Medicaid Fraud Control Unit - New York State Attorney General
08.1999 - 09.2003
Jack Welch Management Institute At Strayer University - Master of Business Administration,
Norwich University, Military College of Vermont - Bachelor of Arts, Criminal Justice Studies

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David A. Duhaime