DELIA C. BUENO
Las Cruces,NM
Summary
Talented Manager with expert team leadership, planning and organizational skills built during successful career. Smoothly equip employees to independently handle daily functions and meet customer needs. Diligent trainer and mentor with exceptional management abilities and results-driven approach.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Retrospective Manager
OptumHealth
04.2020 - 08.2023
- Managed and motivated employees to be productive and engaged in work.
- Accomplished multiple tasks within established timeframes.
- Maintained professional, organized, and safe environment for employees and patrons.
- Resolved staff member conflicts, actively listening to concerns and finding appropriate middle ground.
- Onboarded new employees with training and new hire documentation.
- Maximized performance by monitoring daily activities and mentoring team members.
Senior Investigator
OptumHealth
09.2016 - 04.2020
- Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue.
- Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met.
- Collaborate with clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances.
- Gather all relevant facts to articulate behavior through and Investigation Summary and compliance package. Communicate clear rationale for investigation processes and outcomes to Client, Regulator and Stakeholders.
- Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP Submission.
- Perform member and provider interviews, and review medical documentation and needed.
- Communication with legal, Law Enforcement, clients and business partners as needed.
Investigator
OptumHealth
09.2011 - 09.2016
- Responsible for regulatory compliance for multiple contracts and clients
- Ensures FWA issues are handled timely and in accordance with applicable laws and regulations
- Manages team of investigators who are responsible for investigating and recovering/resolving suspect and/or fraudulent Behavioral Health claims
- Conducts detailed reviews on claims that have been identified as suspicious and/or potentially fraudulent
- Monitors and Solutions for suspicious providers, gaps in clinical policy, provider contract issues, system configuration and pricing errors, claim processor errors (manual or system processed)
- Provides leads on potential post-payment investigations
- Responsible for training new employees
- Coordinates with investigators to continually provide updates on newly identified billing/coding trends.
Claim Funding Specialist
Optum Health New Mexico
01.2009 - 01.2011
- Responsible for insuring claims were being process correctly and being paid correctly according to provider contract agreements
- Troubleshooting claims and discover trends that might be affecting claims
- Run provider claim data reports and analysis billing
- Provide provider training and answer billing questions
- Onsite auditing, research claims and pre-auth information
- Resubmit claim to be adjusted
- Received the Hero award which is one of the awards given by Optum for exceptional performance.
Manager/Appeal Coordinator
El Paso Orthopaedic Surgery Group
01.2007 - 01.2009
- Responsible for managing provider contracts
- Negotiate fee schedule rates
- Credentialing all providers
- Update provider information
- Renew provider medical licenses
- Payment posting and charges
- Submitting secondary claims; setting up electronic claims, and remits; correcting denied claims and appealing claims
- Medical billing/coding
- Collections
- Customer service
- Responsible for submitting daily/weekly/and monthly financial reports
- Manager of Medical Present Value program.
Security Officer
NASA-Johnson Space Center, Wackenhut Security Services
01.2006 - 01.2008
- Responsible for securing outer perimeter
- Managed control base access
- Report writing daily log reporting
- Foot patrol
- Vehicle inspections/checks
- Visitor escorts
- Visitor processing duties
- Traffic stops
- Safety briefings
- Vehicle registrations
- Team lead
Education
Certified Fraud Examiner - Financial Forensics And Fraud Investigation
Association of Certified Fraud Examiners
Austin03.2015
Associates - General Studies
New Mexico State University
Las Cruces, NM12.2014
SOFCC Certified-Security Officer Fundamental Certification Course - Security Services Administration And Management
NASA
Houston, TX08.2006
Law Enforcement Certification - Law Enforcement
New Mexico Western University
Silver City04.1991
Skills
Managerial Experience
Rats-stats
Excel and Pivots
Member interview and Onsite
Detail oriented
Quality focused
Bilingual (English-Spanish)
Strong Communication skills
Excellent Customer Service skills
Regulatory Compliance
Ability to train others
Certification
- Certified Fraud Examiner
- Certified Fraud Examiner SOFCC Certified-Security Officer Fundamental Certification Course
Additional Information
- 17 years Special Investigation Unit (SIU) /Payment Integrity & Managed Services (PNI)/FWA
- Behavioral Heath/Medical Fraud and Abuse Investigations,
- Provider Contracting Behavioral Health, Medical and Dental
- Validation
- Claims, Billing, Adjustments, Appeals
- Coding experience
- Member interviews and Onsite
- Law Enforcement experience
- Regulatory and compliance
Timeline
Retrospective Manager
OptumHealth
04.2020 - 08.2023
Senior Investigator
OptumHealth
09.2016 - 04.2020
Investigator
OptumHealth
09.2011 - 09.2016
Claim Funding Specialist
Optum Health New Mexico
01.2009 - 01.2011
Manager/Appeal Coordinator
El Paso Orthopaedic Surgery Group
01.2007 - 01.2009
Security Officer
NASA-Johnson Space Center, Wackenhut Security Services
01.2006 - 01.2008
Certified Fraud Examiner - Financial Forensics And Fraud Investigation
Association of Certified Fraud Examiners
Associates - General Studies
New Mexico State University
SOFCC Certified-Security Officer Fundamental Certification Course - Security Services Administration And Management
NASA
Law Enforcement Certification - Law Enforcement
New Mexico Western University