Summary
Overview
Work History
Education
Skills
Accomplishments
Certification
Additional Information
Languages
References
Applications
Skills
Timeline
Generic

Evelyn Ortiz

Tampa,FL

Summary

Results-driven Medical Data Analyst specializing in fraud detection and data analysis at Delta Group. Enhanced claim accuracy and reduced loss ratios through meticulous investigations and effective database management. Proficient in statistical modeling and experienced in collaborating with cross-functional teams for timely resolutions.

Overview

27
27
years of professional experience
1
1
Certification

Work History

Medical Data Analyst

Delta Group
, Remote
05.2017 - Current
  • Collaborated with insurance claim adjusters to investigate hospitals and facilities across U.S.
  • Conducted patient information gathering related to work injuries.
  • Entered collected data into a canvass and uploaded it into a database application.

SIU Investigator

Avis Budget Group
06.2010 - 09.2016
  • Investigated potential fraudulent activity
  • Worked closely with NICB and IBC agents to pursue perpetrators of insurance fraud
  • Cooperated with Ontario Rings Investigation Unit and Toronto Police law enforcement community to help put fraud perpetrators out of business
  • Trained claims adjusters and examiners to look for 'red flags', or indicators that fraud might be occurring
  • Review initial referral; evaluate claim and underwriting information to identify appropriate resource and investigative strategies
  • Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy
  • Maintain and ensure accurate and timely documentation in the SIU tracking database
  • Ability to handle multiple priorities/projects in a fast-paced professional environment
  • Conducted an In-person clinic inspection in an active fraud ring investigation
  • Interviewed claimants involved in fraud ring at the plaintiff attorney office
  • Demonstrate performance in meeting time-sensitive deadlines with minimal supervision
  • Interviewed subjects, targets and witnesses for information verification and corroboration
  • Collaborated with examiners, legal staff, the Attorney General's office and other law enforcement agencies of the investigation action plan and recommendations on further action as needed
  • Coordinated the EUO process for the PIP team and defense counsel

PIP Examiner II

Avis Budget Group
04.2008 - 06.2010
  • Reduced loss ratios through fair and prompt processing of claims
  • Obtained relevant evidence and information regarding suspicious claims
  • Interviewed claimants, medical specialists and employers to determine pertinent claim information
  • Managed a caseload of 350 clients each quarter
  • Conducted interviews, gathered detailed information
  • Investigated any potentially fraudulent claims with a focus on thoroughness, quality and cost control
  • Mentored 6 new members of the claim staff
  • Developed connections with local fraud bureaus, district attorneys' offices and professional associations
  • Contacted injured parties and legal representatives to negotiate final settlements for claims
  • Explained premiums owed to policyholders, agents and underwriters
  • Completed required investigations on referred files in a timely manner
  • Drafted statement of loss to summarize damages, payments and underlying policy coverage
  • Kept up-to-date on changes in regulations for deductibles and collections

TCR2 Examiner

Geico
01.2004 - 01.2007
  • Investigated claims against insurance for personal, property loss and damages
  • Presented cases and participated in their discussion at claim committee meetings
  • Verified and analyzed data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures
  • Supervised claims adjusters to ensure that adjusters had followed proper methods
  • Investigated, evaluated and settled claims, applying technical knowledge and human relations skills to effect
  • Maintained claim files, such as records of settled claims and an inventory of claims requiring detailed analysis
  • Responded to written and telephone requests for bilingual customers
  • Resolve claims by investigating losses negotiating settlements
  • Examine claim forms, policies and endorsement, client instructions and other records to determine liability

Personal Injury Protection Specialist II

Geico
01.1998 - 01.2004
  • Research and responds to complex customer communications, concerns, conflicts or issues
  • Summarizes documents and enters into claim system notes, documenting a claim file with notes, evaluations and decision-making process
  • Utilized analytic tools or SIU field intelligence to identify complex claims for investigation and/or for support in the evidence of the fraud and damages
  • Conducted thorough investigations of complex that are potentially fraudulent to determine if payment is warranted
  • Validate that the information provided and obtained through investigation is true and accurate and follows up on all possible leads
  • Conducted complex online data application searches, research, and evaluation
  • Review investigations with fraud outcomes to validate whether denial is appropriate
  • Update files with investigation outcome, and when no fraud or insufficient evidence is found, returns file to MCO for further handling and settlement
  • Entered SIU claim data information into multiple SIU systems
  • Made claim decisions regarding complex investigations, and pursues restitution

Education

Some College (No Degree) - Business Administration And Management

Baruch College
New York, NY

Skills

  • Data analysis and visualization
  • Database management
  • Fraud detection
  • Statistical modeling
  • Microsoft Excel

Accomplishments

  • Recipient of the Toronto Police Project Whiplash Award in May, 2015 for investigative work leading to the collaboration and communication in the success of Project Whiplash, an investigation into organized insurance crime activity including staged collision and associated injury claims.

Certification

True, 01/14/24, Evelyn Ortiz

Additional Information

In 2013, honored by The Insurance Bureau of Canada., In 2015, received a recognition letter from Avis Budget Group Litigation Manager., The National Insurance Crime Bureau accepted 16 of my questionable claims submission.

Languages

3

References

Vince Moffa, Senior Manager, Litigation Team

Kirk Quinn, Ontario Team Leader Injury Rings Investigative Unit

Applications

  • Abacus
  • NICB Forewarn Alerts
  • ISO Claim Search
  • Damage Manager Portal
  • Casetrack
  • G4S
  • ZipCar Website
  • Accurint

Skills

  • Multi line phone

Timeline

Medical Data Analyst

Delta Group
05.2017 - Current

SIU Investigator

Avis Budget Group
06.2010 - 09.2016

PIP Examiner II

Avis Budget Group
04.2008 - 06.2010

TCR2 Examiner

Geico
01.2004 - 01.2007

Personal Injury Protection Specialist II

Geico
01.1998 - 01.2004

Some College (No Degree) - Business Administration And Management

Baruch College

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Evelyn Ortiz