Janel Patrice
Tampa,FL
Overview
4
4
years of professional experience
Work History
Principal Investigator/Investigations Consultant
UnitedHealthcare Group
07.2023 - Current
- Triaging, investigating, and managing a monthly caseload of approximately (35) cases of healthcare fraud, waste and abuse for the State of Florida, involving all lines of business/ Commercial, Medicaid, FEHB, Unet, and Medicare
- Utilizing Tableau and other investigative tools to investigate SIU tips/complaints from plan members, the medical community and law enforcement, through confidential documents and investigations
- Utilizing data mining for large data sets, with use of pivot tables, to identify emerging fraud patterns to measure and track aberrant billing by medical providers
- Attending NHCAA conferences and completing public presentations to executive leadership on healthcare fraud trends within the state of Florida
- Enforcing and monitoring compliance with legal regulations, industry trends, and policies within UHC
- Providing recommendations and improvements to providers throughout the investigation process with Provider Education letters and meetings
- Negotiating fraud exposure with applicable stakeholders (e.g., providers, attorneys, clients, Network staff), to ensure and validate appropriate actions taken during the investigation process
- Monitoring and analyzing large volumes of data to detect emerging fraud trends, devising proactive strategies to mitigate risks and enhance fraud prevention mechanisms
- Completing monthly/quarterly audit summaries for managed cases
- Creating an evidence package for Law Enforcement Agencies, contract holders, and state insurance fraud bureaus, and additional parties
- Overseeing UHC patient and provider interviews and on-site inspections as needed
- Responding to subpoenas and information requests from State Departments of Insurance and law enforcement
- Completing specific projects requiring knowledge in claim auditing, fraud detection, investigation, and other fields connected to special investigations
- Conducting on-site inspections and assisted others with inspections, to retrieve medical records and provider interviews during SIU Investigations.
Employee Relations Investigator/Staff Support Specialist
Community Services Foundation
06.2020 - Current
- Investigating employee complaints and critical incidents and completing high quality written investigation summaries and reports independently, partnering with appropriate personnel throughout the investigative process
- Gathering and securing relevant evidence and documentation, with detailed background investigations, and recorded interviews; Working as the primary liaison for employees in resolving HR issues
- Responding to all critical incident reports, inclusive of shootings, child and sexual abuse allegations and inappropriate employee behaviors
- Creating, revising and modifying policies, procedures and processes within the organization, and providing to upper management for approvals
- Providing external referral resources to staff and residents requiring mental health and additional services
- Demonstrating an understanding of laws, regulations, concepts, and practices applicable to workplace investigations, accommodations, and leave, and advise the human resources team in partnership with People Legal, as needed
- Providing empathy and diplomacy with difficult and uncomfortable situations and conversations surrounding an investigation
- Primary contact to investigate and resolve HR inquiries directed from various business unit clients, union representatives and HR partners (e.g
- Sr
- HR Specialists, HR Generalists, Legal, Labor Relations, etc.)
- Analyze and confer expertise relating to HR inquiries
- Developing and delivering performance management training/development tools for business unit clients
- Recommending direction and conferring expertise to a variety of business unit clients on HR issues, policies and practices and non-management collective Bargaining agreements
- Exercising judgment in selecting methods and techniques for obtaining solutions
- Advising and counseling managers on employee-related matters to ensure consistency across business units.
Senior Fraud Investigator
BMTX Technologies- Bank Mobile Digital Banking
10.2022 - 07.2024
- Reported fraud trends using fraud reports and live monitoring
- Monitored and analyzed large volumes of data to detect emerging fraud trends, devising proactive strategies to mitigate risks and enhance fraud prevention mechanisms
- Assisted with the development and implementation of fraud prevention tools, technologies, and methodologies to strengthen the overall security posture of the organization
- Recorded incoming and outgoing documentation Verafin Case Management Tool system, and communicated with VIBE account holders, and company Program Administrators on a regular basis
- Managed and assigned daily charge report cases and deposit fraud alerts in Verafin to VIBE teammates
- Provided guidance and support to Bank Mobile teammates for VIBE, while sharing insights, best practices, and knowledge to foster skill development within the team
- Conducted thorough investigations while identifying suspicious accounts within the specified systems
- Investigated and gathered information on fraud cases including contacting merchants, and financial institutions and/or clarifying customer statements as necessary
- Reviewed alerts/reported to detect Suspicious and prepping cases for SAR
- Completed periodic internal account/customer reviews to identify potentially fraudulent activity
- Reviewed disputed transactions to investigate fraud claims, identifying charge-back opportunities, and ensuring compliance with regulations within timeframes that govern disputed transactions
- Responded promptly while exercising exceptional communication skills to optimize each contact with customers, partners, and external vendors/banks
- Stayed current with industry developments and emerging fraud patterns to continuously enhance the organization's fraud prevention strategies
- Case management of 20-50 suspected fraud claims under ID Theft, Deposit Fraud, ACH Fraud, Check Fraud and possible compromised accounts, through Verafin/Ensenta/IBS systems
- Communication skills to optimize each contact with customers, partners, and external vendors/banks.
BMTX Technologies October
- Bank Mobile Digital Banking
10.2022 - 07.2024
Senior SIU Investigator
CVS/AETNA
- 06.2023
- Completed complex fraud Investigations with managed caseload (25-30) on known Medicaid/Medicare Providers suspected of healthcare fraud, waste, and abuse
- Independently lead analytical investigations with medium to high risk or complexity
- Analyzed information gathered by investigation/audit and report s, and reported those findings within a written summary report, with recommendations
- Prepared evidence packages for referrals to third parties, to include provider networks, state insurance fraud bureaus and law enforcement agencies
- Lead and assisted others with on-site inspections and patient/provider interviews as necessary
- Completed special projects, requiring expertise in fraud detection, investigation, claim auditing and other areas related to Special Investigations
- Prepared reports to expedite tracking and reporting of investigations.
Senior Lead SIU Auto Investigator/Manager
Lemonade Insurance Company
11.2021 - 11.2022
- Managed (5) Investigators and conducted Investigations with managed caseload on fraudulent property and casualty claims to include auto burglary, fire, theft, and liability
- Served as a lead and investigated all possible fraud claims
- Monitored business processes and systems to assure integrity and compliance in within SIU
- Reviewed educational materials to identify fraudulent activities, and coached others to identify fraud activity within the claims process
- Prepared and distribute monthly and quarterly reports
- High utilization of Lexis Nexis, and ISO, and Microsoft excel systems to identified fraudulent activity
- Collaborated closely with internal and external stakeholders, including claims adjusters, legal teams, and other insurance professionals, to coordinate investigations
- Conducted thorough investigations into insurance claims displaying indicators of potential fraud or suspicious activity
- Interviewed claimants, witnesses, and other relevant individuals to gather information for auto, home, fire, theft and personal liability claims
- Gathered and analyzed evidence, including documents, witness statements, recorded statements, and surveillance footage
- Prepared detailed reports outlining findings and recommendations for further action
- Identified opportunities to streamline and create efficiencies for continuous process improvement
- Performed management functions, such as validating investigative process workflows in the corporate security manual and ensuring responses to client complaints are timely and appropriate
- Developed and implemented client and associate fraud awareness initiatives, including education, prevention, best practices, detection, and response programs by method of formal training and through various platforms with other functional areas.
Senior SIU Investigator/Team Leader
Arthur J. Gallagher Corporation
06.2020 - 11.2021
- Certified Parole/Probation Officer States of Michigan/Florida Corrections January 1995-February 2015
Education
Ed. D -
Argosy University
Master of Arts - Counseling
Webster University
Bachelor of Science - Criminal Justice
University of Toledo
Skills
- Microsoft Excel/Word/Sharepoint
- Public Speaking/Powerpoint
- Risk Management/ISO
- HIPAA
- Motivational Interviewer
- Optum Encoder/Pro
- Healthcare Fraud Shield
- Employee Relations
- Customer Advocacy
- Verafin/EnSenta/IBS
- SAR Reports/Medical Records
- CIMS/NDB/ICUE Systems
- Java/Tableau/SLQ/Lexis Nexis
- Ensenta/Verafin
Certificationsaffiliations
- Law Enforcement Certification CJSTC (Criminal Justice Standards & Training Commission)
- Former 620 Adjuster License
- NHCAA/AFHI Affiliated
- Florida Counselors Association
- National Alliance on Mental Illness
- Delta Sigma Theta Sorority, Inc. (1993)
- American Counseling Association (ACA)
- HealthCare FWA
- Mental Health
- Healthcare Fraud Shield
- Re-writing Policies/Procedures
- Building/Launching Programs
- Identifying/Mitigating Risk
- Fraud Trends
- Training
- CPT/ICD Code Knowledge
Timeline
Principal Investigator/Investigations Consultant
UnitedHealthcare Group
07.2023 - Current
BMTX Technologies October
- Bank Mobile Digital Banking
10.2022 - 07.2024
Senior Fraud Investigator
BMTX Technologies- Bank Mobile Digital Banking
10.2022 - 07.2024
Senior Lead SIU Auto Investigator/Manager
Lemonade Insurance Company
11.2021 - 11.2022
Senior SIU Investigator/Team Leader
Arthur J. Gallagher Corporation
06.2020 - 11.2021
Employee Relations Investigator/Staff Support Specialist
Community Services Foundation
06.2020 - Current
Senior SIU Investigator
CVS/AETNA
- 06.2023
Ed. D -
Argosy University
Master of Arts - Counseling
Webster University
Bachelor of Science - Criminal Justice
University of Toledo