Kareem McKinnie
Sanford,NC
Summary
Known for process optimization, continuous learning, and team leadership. Results-oriented analyst specializing in claim adjustment, SIU recovery resolutions, and SIU prepay investigation in health insurance industry. Proven track record of delivering accurate and efficient claim resolutions while maximizing cost recovery and mitigating fraud risks. Strong analytical and problem-solving abilities combined with excellent interpersonal and communication skills. A dedicated team player with a commitment to delivering exceptional customer service and achieving organizational goals.
Overview
15
15
years of professional experience
Work History
Special Investigative Unit Prepay Investigator C&S
Optum Services
02.2019 - Current
- Discover abnormal billing trends through data collection methods and analysis strategies and use the information to help implementation and management of SIU flags and prevent fraudulent claim payouts
- Collaborate with coding consultants and post-pay personnel to facilitate case resolution and conduct root cause analysis of claims and/or case processing, resulting in a 20% decrease in cases of fraud and abuse
- Independently managed multiple claims applications and over a dozen internal and external applications, resulting in streamlined research processes and more efficient decision-making
- Conducted interviews with witnesses and clients.
- Create executive summary reports, to assist in getting flag either altered or removed
- Conducted on-site visits to medical offices to corroborate instances of fraudulent activity
SIU Prepay Analyst
Optum Services
02.2018 - 02.2019
- Implemented data-driven approaches to identify trends and patterns in overpayment cases, resulting in a 10% improvement in detection accuracy and increased recovery rates
- Performed audits of subsidiaries to protect shareholders and potential investors from fraudulent or unrepresentative medical claims
- Attended NCHAA fraud presentations enhancing expertise and credibility in fraud detection and investigation
- Analyze and Identify trends and provide reports; ensure adherence to state and federal compliance policies
- Improved internal knowledge sharing by developing comprehensive documentation outlining standard operating procedures for various tasks.
Claims Research Specialist, Medicare Reclamation
United Healthcare
04.2016 - 02.2018
- Provide expertise by researching and investigating UNET claims history for claims found to be paid/denied primary or paid/denied secondary Authorize appropriate payment in TRCR2
- Followed all company policies and procedures to deliver quality work.
- Providing investigating and contacting AMTs for demand documentation for any eligibility issues
- Pay or deny Medicare secondary payer demands according to research
- Improved client satisfaction through timely communication and resolution of account discrepancies.
Combined Accumulator Reconciliation Team
United Healthcare
09.2014 - 04.2016
- Provide expertise or general claims support by reviewing, negotiating, processing, and adjusting claims
- Reconciled accounts, managed audits and updated financial records with remarkable accuracy.
- Authorize appropriate payments or refers claims to investigators for further review
- Analyze and identify trends and provide reports, as necessary
- Constantly meet established productivity, schedule adherence, and quality standards and provide excellent customer service
Customer Service Administrator
Butterfield Bank
03.2009 - 07.2014
- Enhanced customer satisfaction by efficiently addressing and resolving inquiries, complaints, and concerns.
- Developed strong relationships with customers by actively listening, understanding their needs, and providing relevant solutions.
- Updated customer service database with new information, address changes and contact details.
- Answered incoming calls and emails from current customers and asked open-ended questions to determine needs.
- Assisted customers with completing loan applications and other paperwork.
Education
Skills
- Macess
- Detailed report writing
- Interview techniques
- Research abilities
- Facets
- Teamwork and Collaboration
- Attention to Detail
- Problem-Solving
- Analytical Thinking
- Fraud prevention
- CPT / ICD-10 Methodology
Timeline
Special Investigative Unit Prepay Investigator C&S
Optum Services
02.2019 - Current
SIU Prepay Analyst
Optum Services
02.2018 - 02.2019
Claims Research Specialist, Medicare Reclamation
United Healthcare
04.2016 - 02.2018
Combined Accumulator Reconciliation Team
United Healthcare
09.2014 - 04.2016
Customer Service Administrator
Butterfield Bank
03.2009 - 07.2014
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