Janel Patrice
Tampa,Florida
Summary
PERSONAL OBJECTIVE
Detail oriented Investigator with strong leadership skills and diverse background in human resources/employee relations, criminal investigations, healthcare fraud, waste, and abuse, and property/casualty. Law Enforcement certified with NHCAA/AFHI affiliations, and mental health background. Driven analytical professional with talent for critical thinking and problem-solving. Extraordinary public speaker, trainer, and motivational interviewer, with an outstanding personality, and willingness to learn. Highly skilled at analyzing large data sets, fostering positive collaborations, while delivering high quality results. Proactive and goal-oriented with excellent time management skills. Seeking to secure a remote role in Employee Relations.
Overview
31
31
years of professional experience
Work History
Principal Investigator/Investigations Consultant
UnitedHealthcare Group
07.2023 - Current
- Triaging, investigating, and managing a monthly caseload of (35) cases involving healthcare fraud, waste, involving all lines of business/ Commercial, Medicaid, FEHB, UNET, and Medicare.
- Utilizing data mining through Microsoft Excel/Pivots, involving large data sets, to identify emerging fraud patterns to measure and track aberrant billing by medical providers.
- 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.
- Completion of onsite Investigations within the state of Florida.
- 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.
- Receiving, processing, and filing medical records.
- Researching, identifying, and reviewing CPT/HCPCS codes to identify aberrant billing.
- Completing monthly/quarterly audit summary reports for managed cases.
- Creating an evidence package for CMS, Law Enforcement Agencies, contract holders, and state insurance fraud bureaus, and additional parties.
- Completing patient and provider interviews.
- 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.
- Retrieving, reviewing and sorting medical records, and conducting interviews with Providers and members.
Employee Relations Investigator/Staff Support Specialist
Community Services Foundation
06.2020 - Current
- Managing (20) complex employee relations related investigations independently, end-to-end, including allegations of discrimination, harassment, retaliation, bullying, misconduct, bias, and other inappropriate behavior.
- Providing coaching, expertise, and consultation to employees on behavior modification, conflict resolution, and disciplinary issues in accordance with company policies.
- Investigating and resolving workplace issues such as discrimination, harassment, and workplace violence, while supporting managers and employees on complex issues.
- Responding to all critical incident reports, inclusive of shootings, child and sexual abuse allegations and inappropriate employee behaviors.
- Educating leadership on federal and state employment laws to ensure compliance.
- Creating, revising and modifying contracts, grants, policies, procedures and processes within the organization, while ensuring compliance with legal and regulatory requirements.
- Providing external referral resources to staff and residents requiring mental health and additional services.
- Providing empathy and diplomacy with difficult and uncomfortable situations and conversations surrounding an investigation, while utilizing motivational interviewing techniques.
- Conducting phone contacts with employees to investigate and resolve HR inquiries directed from various business unit clients, union representatives and HR partners.
- 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, contracts, policies and practices and non-management collective bargaining agreements.
- Servicing as the Agency Advisor in establishing, developing and maintaining effective working relationships with internal/external stakeholders,
- 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 calls with case documentation in the Verafin Case Management Tool system, and communicated with VIBE account holders, by phone and in writing.
- Managed and assigned daily VIBE BOPS referrals, ACH wire fraud alerts, Verafin queue alerts, charge report cases, and deposit fraud alerts 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 identifying fraudulent check items in ESENTA and IBS systems, while identifying compromised and ID Theft accounts, within the specified banking systems.
- Investigated and gathered information on fraud cases by contacting merchants, and financial institutions and/or clarifying customer statements as necessary via recorded statements.
- Completed SAR prep reports and case summaries for SAR cases.
- 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.
- Utilized communication skills to optimize each contact with customers, partners, and external vendors/banks.
Senior SIU Investigator
CVS/AETNA
06.2022 - 06.2023
- Completed complex fraud Investigations with managed caseload (25-30) on known Florida 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, and extensive reports, for Florida AHCA, MFUCU and other provider networks, and the US Office of Inspector General Office.
- 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.
- Utilized Lexis Nexis/Accurint and dissected large data sets via pivot tables (Microsoft Excel).
- Completed extrapolations under the UWID/QNext software systems.
- Researched, identified, and secured cases of Healthcare fraud, waste, and abuse in the Healthcare Fraud Shield system.
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 distributed 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
06.2019 - 11.2021
- Investigated complex PIP claims to include fatalities, and fraud schemes involving 1st party Insureds, medical providers, and Attorneys, while reviewing PIP exposures and underwriting.
- Completed research through internal/external engines and reporting activity to NICB.
- Completed recorded statements and submission of fraud findings to NICB.
- Attended depositions and medically disputed PIP claims with sworn testimony.
- Utilized internal/external investigative search engines for fraudulent claims/Trainer.
- Investigated claims through telephone, written correspondence, and/or personal contact with claimants, attorneys, insureds, witnesses and others having pertinent information.
- Analyzed information to evaluate claims that were assigned, to determine exposure to the insured and company.
- Identified opportunities for SIU claims process improvements, completed power point presentations and trainings for claims adjusters, while developing and contributing to best practices in SIU investigative policy and procedures.
- Effectively and efficiently presented claims, to include claim trends to Underwriting Leadership, with discussion of coverage, liability assessments and ultimate exposures.
- Used metrics analysis and analysis to find fraud tendencies and weaknesses.
Certified Parole/Probation Agent
States of Michigan and Florida
01.1994 - 06.2017
- Improved offender rehabilitation by conducting thorough assessments and developing individualized case plans.
- Managed caseload of (100) Mental Health, Sex Offenders, and other Criminal Offenders.
- Created and administered a mental health program, to service delivery, assessment, surveillance, quality assurance, partnerships and collaborations, outreach, orientation, training, reporting, and program implementation and evaluation.
- Developed training materials using designs and multimedia programs.
- Reviewed, redacted, and edited contracts, policies and procedures for the State of Florida.
Education
Ed. D - Education, Counseling, Supervision
Argosy University
Master of Arts - Counseling
Webster University
Meritt Island, FloridaBachelor of Science - Criminal Justice
University of Toledo
Toledo, OhioSkills
- Microsoft Suite, Excel/Word/Sharepoint/Pivot Tables
- Public Speaking/Powerpoint
- Contract Management
- Risk Management/ISO
- HIPAA
- Motivational Interviewer
- Optum Encoder/Pro
- Healthcare Fraud Shield
- Employee Relations Investigations
- Criminal, P&C, Bank, HealthCare FWA
- Customer Advocacy
- SAR Reporting
- HCPCS Codes/Medical Record Reviews
- CIMS/NDB/ICUE Systems
- Java/Tableau/SLQ/Lexis Nexis Systems
- Verafin/EnSenta/IBS
- Collaborative Research
- Policy Re-writes
- Collaborative research
- Human Resources/Ethics
- Case Management
Certifications/Affiliations
- 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)
Timeline
Principal Investigator/Investigations Consultant
UnitedHealthcare Group
07.2023 - Current
Senior Fraud Investigator
BMTX Technologies- Bank Mobile Digital Banking
10.2022 - 07.2024
Senior SIU Investigator
CVS/AETNA
06.2022 - 06.2023
Senior Lead SIU Auto Investigator/Manager
Lemonade Insurance Company
11.2021 - 11.2022
Employee Relations Investigator/Staff Support Specialist
Community Services Foundation
06.2020 - Current
Senior SIU Investigator/Team Leader
Arthur J. Gallagher Corporation
06.2019 - 11.2021
Certified Parole/Probation Agent
States of Michigan and Florida
01.1994 - 06.2017
Ed. D - Education, Counseling, Supervision
Argosy University
Master of Arts - Counseling
Webster University
Bachelor of Science - Criminal Justice
University of Toledo
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