Jimmy Christopher Camero
Homestead
Summary
Proven experience in client services, underwriting, and claims investigations. Excellent communication and people skills, results oriented. Comfortable working independently as well as in a team environment. Seeking to obtain a prominent position that will exemplify experience, organizational skills, and dependability as an employee and as a person. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Provider Configuration Analyst
Doctors Healthcare Plans
03 2024 - Current
- Improved configuration processes by streamlining workflows and implementing automation tools.
- Provided timely support for end-users, resolving configuration-related issues quickly and effectively.
- Conducted root cause analyses of configuration issues, identifying areas for improvement and implementing corrective actions accordingly.
- Ensured compliance with company standards by conducting thorough configuration audits.
- Facilitated information sharing among team members through regular meetings and discussions, fostering a collaborative work environment focused on continuous improvement.
- Developed customized reports for senior management, highlighting key trends and insights on fraud-related issues.
- Identified emerging fraud trends by conducting regular market research and staying updated on industry best practices.
- Collaborate with the Special Investigations Unit team to identify fraud trends with providers in network with the plan.
- Run claims and provider reports to identify any non compliant rules in place within the system
- Resolve claims, contract, and provider maintenance tickets submitted by various departments.
- Experience in processing all UB-04 and 1500 claim form For medicare and D-SNP Medicaid members.
- Update quarterly fee schedules and collaborate with IT and operations analysts to identify configuration problems with benefits and provider contracts.
Fraud Investigator
Ascendant
03 2023 - 03 2024
- Summarized all key information regarding investigation into detailed report for delivery to client.
- Interviewed witnesses thoroughly, asking appropriate questions to ascertain critical details about each case.
- Reviewed reports and individual transactions which appeared suspicious to uncover possible fraudulent activity.
- Performed risk assessments to determine level of fraud risk and prioritize investigations.
- Analyzed large amounts of data to find patterns of fraud and anomalies.
- Produced detailed reports of fraud investigations and presented findings to senior management.
- Tracked fraud cases and monitored trends to develop strategies for prevention.
- Testified in court for both civil and criminal cases, answering questions honestly and respectfully.
- Conducted prompt and thorough investigations on referred files.
- Worked with third-party vendors to access and analyze data and systems.
- Established and maintained positive working relationships with external law enforcement agencies to support fraud investigations.
Claims Specialist
Assurant
2021.07 - 2023.03
- Explains all applicable coverage benefits to the policyholder
- Confirms facts of loss
- Investigates and confirms coverage for claims with low complexity coverage issues including claims where coverage is reportedly clear and new business investigations
- Communicates liability decision to customers, claim specialists, and Underwriting
- Recognizes subrogation potential and makes referrals to Subrogation department when appropriate
- Investigates and recognizes all potential claim exposures
- Escalates claims with exposures exceeding financial authority and Tier 1 complexity criteria to Supervisor
- Monitored defense counsel's activity and ensured proper legal strategies were being exercised
- Monitored defense counsel's legal fees to ensure there were in line
- Prepared necessary reports to management such as file reviews, authority requests, coverage question reports, litigation plans, reports for denials, etc
- Ensured all bills associated with files were paid in a timely manner and billed for reasonable and necessary charges.
- Prepared an investigation report by analyzing written reports, contracts and public records.
- Assisted in the development, maintenance and implementation of accident reporting and complaint handling procedures.
- Conducted extensive field investigations of vehicle accidents involving agency vehicles and other accidents.
- Interviewed drivers, witnesses, investigating officers, tow truck operators and others.
- Able to investigate claims for fraud, staged accidents, and misrepresentation.
- Managed the claims to decide when an independent medical exam was appropriate to set up for a second opinion.
- Had to assess coverage and confirm if the same should be afforded.
- Promoted to handling clear cut liability claims, then disputed claims, then subrogation, then medical payments, then bodily injury claims.
- Investigated accident reports to determine culpability/liability and estimate potential claim exposure.
- Investigated the findings of medical indexing to help evaluate and settle third-party injury claims.
Property and Casualty Claims Adjuster
Assurant
2019.06 - 2021.07
- Communicate with policy holders, clients, police, and necessary parties to adjudicate claims per state guidelines
- Experience mentoring and training new team members
- Under technical direction, use discretion and independent judgment to analyze claim forms, policies and endorsements, client instructions and other records to determine whether the loss falls within the policy coverage.
- While speaking to our customers via phone / face to face video, investigates, determines coverage of loss, and adjusts all elements of routine property loss claims.
- Under minimal supervision, is responsible for planning and executing the processing of assigned first party property claims that are of mid to high complexity and / or severe in nature from beginning to end.
- Direct outside vendors and experts retained to assist in the claim investigation, and closely control claims costs.
- Prepare written reports of investigation findings
- Interview witnesses or suspects and take statements.
- Maintain knowledge of current events and trends in such areas in fraud, waste, and abuse.
- Recommend actions in fraud cases.
- Identify and articulate red flags, suspected fraudulent activity, material misrepresentation and other indicators of insurance fraud.
Claims Representative
Simply Healthcare Plans
2018.03 - 2019.05
- Investigated overpayments and funds requirements
- Manage and distribute co-pays, co-insurance maximums and provider settlements
- Investigate claims that uncovered fraud and potential fraud
- Provider Services Unit (Claims) -Adjusted voids and reopens claims on-line within guidelines to ensure proper adjudication
- Knowledge of medical insurance codes and government guidelines
- Able to review both facility and physician claims
- Determined when adjustments may be due for incorrectly processed claims
- Review all Medicaid and Medicare claims inquires and apply processing rules to determine allowable benefits for payment
- Reviews services for appropriateness of charges and considers system edits and also determines exclusions and denials based on contract provisions
- Documents all calls in the inquiry tracking system ensuring complaints and grievances
- Experience with multiple systems: FACETS, QNXT (TRIFECTA) PEGA, COMPASS, MACESS etc., familiar with all Medicaid and Medicare billing guidelines.
Security/Surveillance Agent
Magic City Casino
2013.03 - 2018.03
- Observe, monitor and report suspicious activity to Supervisor and off- duty police officers on site
- Transport large sums of currency from slot machines to main vault in casino
- Communicate directly with the surveillance team using radio 10 codes and inform and educate patrons on the rules of the state of Florida ran casino.
- Greeted guests professionally and courteously to cultivate welcoming atmosphere while making safety top priority.
- Checked identification of persons entering and exiting facility to eliminate unauthorized visitors.
- Oversaw daily monitoring and patrolled buildings, grounds, and work sites.
- Checked and verified photo identification prior to granting facility access.
- Patrolled and monitored premises in company vehicle, on bicycle, and by foot.
- Acted quickly during emergency situations to reduce opportunity for damage and injury.
- Protected facility and property guests by regularly circulating premises and monitoring surveillance feeds.
- Monitored security cameras for improper actions by patrons and dealers.
Material Handler
Miami Dade County Public Schools
2010.01 - 2013.12
- Distribute standardized test throughout Miami-Dade county Public schools
- Communicate with school employees on testing material dates and documentation needed for processing
- Implement work plan for test distribution throughout the school year -Ship and receive pallets of important testing material
- Plan and organize truck routes for delivery of all test materials throughout Miami-Dade County.
- Operated forklifts and pallet jacks to transfer large products from one area of warehouse to another, allowing for easier accessibility.
- Kept storage areas organized, clean, and secure to fully protect company assets.
- Listened closely during team meetings to gain complete understanding of duties required for each shift, completing priority tasks first.
- Read production orders, work orders, shipping orders and requisitions to determine items to be moved, gathered, or distributed.
Member Services Representative
Atlantic Dental Plan, Inc
06 2007 - 08 2007
- Handled member calls and documented all calls in the company’s call tracking data base
- Processed returned mail
- Investigated and resolved customer inquiries and complaints quickly.
- Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.
- Exhibited high energy and professionalism when dealing with clients and staff.
- Responded to customer requests, offering excellent support and tailored recommendations to address needs.
Education
High School Diploma -
Christopher Columbus Catholic High School
Miami, FLAssociate of Arts - Criminal Justice Administration / Psychology
Miami Dade Community College
Miami, FLBachelor of Science - Criminal Justice Administration / Psychology
Florida International University
Miami, FLSkills
- Records Research
- Civil Investigations
- Special Projects
- Commercial Property
- Surveillance and Evidence Gathering
- Investigation Techniques
- Trend Analysis
- Litigation Review
- Interviewing Capabilities
- Fraud Investigations
- Fraud Prevention and Detection
- Data Analysis
- Customer Experience
- Social Perceptiveness
- Loss Mitigation
- Workflow Processes
- Corrective Actions
- Microsoft Excel
- HIPAA Compliance
- Healthcare Analytics
- Medicare Regulations
- Medicaid Regulations
Certification
- 6-20 Adjuster License (All 50 States)
- Currently studying for my CFE certification. Expected date of certification exam completion (September 2024)
Languages
Spanish
Professional Working
English
Native or Bilingual
Timeline
Claims Specialist
Assurant
2021.07 - 2023.03
Property and Casualty Claims Adjuster
Assurant
2019.06 - 2021.07
Claims Representative
Simply Healthcare Plans
2018.03 - 2019.05
Security/Surveillance Agent
Magic City Casino
2013.03 - 2018.03
Material Handler
Miami Dade County Public Schools
2010.01 - 2013.12
Provider Configuration Analyst
Doctors Healthcare Plans
03 2024 - Current
Fraud Investigator
Ascendant
03 2023 - 03 2024
Member Services Representative
Atlantic Dental Plan, Inc
06 2007 - 08 2007
High School Diploma -
Christopher Columbus Catholic High School
Associate of Arts - Criminal Justice Administration / Psychology
Miami Dade Community College
Bachelor of Science - Criminal Justice Administration / Psychology
Florida International University
- 6-20 Adjuster License (All 50 States)
- Currently studying for my CFE certification. Expected date of certification exam completion (September 2024)
Similar Profiles
Susel PanecaSusel Paneca
RN Case Manager at Florida Healthcare PlansRN Case Manager at Florida Healthcare Plans
Leah DelcottoLeah Delcotto
Enrollment Specialist at Firstsource Health Plans & Healthcare Services, LLCEnrollment Specialist at Firstsource Health Plans & Healthcare Services, LLC
Lauren OatesLauren Oates
Customer Service Representative at FirstSource Health Plans And HealthcareCustomer Service Representative at FirstSource Health Plans And Healthcare