Kathleen Hoiriis
Summary
Accomplished SIU Prepay Fraud Investigator with a proven track record of success that in investigating processes identifying patterns of fraud, waste and abuse. I have extensive expertise in gathering, analyzing, and reporting findings for internal investigations. Ready to leverage professional experience to remain with Optum during my Redeployment Journey.
Overview
27
27
years of professional experience
1
1
Certification
Work History
SIU Prepay Investigator
Optum
09.2020 - 05.2024
- Identified potential risks by conducting thorough investigations and analyzing patterns.
- Kept current with industry best practices and attended professional development events to maintain expertise in fraud investigation techniques.
- Maintained high level of confidentiality when handling sensitive information, protecting both company reputation and client privacy.
- Conducted prompt and thorough investigations on referred files.
- Reviewed medical records for accuracy during investigative process
- Analyzed large amounts of data to find patterns of fraud and anomalies.
- Documented all key information regarding investigation into detailed report for delivery to client.
- Outgoing phone calls to interview patients, providers, and other partners to ascertain details
- Ensure adherence to state and federal compliance policies and laws
- Translate and investigate foreign medical claims
- Maintain and achieve all departmental metrics for accuracy.
- Highly organized with effective and persuasive communication skills
Senior Quality Assurance Auditor
United Healthcare
09.2016 - 09.2020
- Provide expertise and support by reviewing, researching, investigating and auditing problematic claims
- Analyze and identify trends and provide feedback and reports to reduce errors and improve claims processes and performance
- Responsible for all aspects of quality assurance for multiple lines of business
- Established systems and process to help track identified issues that required further investigation
- Spearheaded internal process improvements that resulted in enhanced operational efficiency within the QA department.
- Collaborated with cross-functional teams to improve overall product quality and compliance.
Senior Customer Service Representative
United HealthGroup
09.2013 - 09.2016
- Consistently exceeded performance targets, earning recognition as a top-performing Senior Customer Service Representative on multiple occasions.
- Properly answered and directed inbound calls in phone queues to improve call flow.
- Reviewed claims for accuracy, completeness, specificity and appropriateness according to services rendered.
- Presented and clearly explained insurance policy options to clients based on their needs and goals.
- Worked as a team player to ensure appropriate changes were made to improve customer satisfaction.
- Promoted client retention through high-quality service and follow through.
Owner/Corporate Financial Officer
Kasmik LLC DBA Neighborhood Property Services
01.2008 - 01.2014
- Managed financial aspects for small business, including budgeting, financial reporting, invoicing and tax preparation.
- Implemented marketing strategies to increase brand awareness and attract new customers.
- Increased customer satisfaction by implementing efficient business processes and providing exceptional service.
- Acted as liaison between insurance companies and tenant during remediation of damaged property.
- Coded claims forms and mediated disputes between carriers and clients.
- Maintained up-to-date knowledge of industry, target accounts and competitive landscape.
Medical Biller / Accounts Receivable
Monadnock Community Hospital
03.2002 - 04.2008
- Performed full-cycle medical billing in a fast-paced full service hospital
- Prepared and attached all required claims documentation including referrals, prior authorizations, treatment plans or other required correspondence to reduce incidence of denials.
- Appropriately and correctly identified errors and re-filed denied/rejected claims once received from insurance carriers
- Conducted month-end balance sheet reviews and reconciled any variances
- Ensured timely and accurate charge submission through electronic charge capture, including billing and account receivables system and clearing house
- Worked with State Agencies to identify and report Abandoned Property
Medical Biller
HealthAlliance Hospital
01.1997 - 03.1999
- Performed full-cycle medical billing in a fast-paced full service hospital, with multiple campus locations
- Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
- Evaluated the accuracy of provider charges, including dates of service, procedures, level of care, locations, diagnoses, patient identification and provider signature.
- Ensured timely and accurate charge submission through electronic charge capture, including billing and account receivables system and clearing house
- Posted charges, payments and adjustments.
- Conducted month-end balance sheet reviews and reconciled any variances
Education
Fraud Case Info Share CEU
National Healthcare Anti-Fraud Association
2024
Associate of Science - Criminal Justice
NHTI-Concord's Community College
Concord, NH2019
Certified Clinical Medical Assistant - Clinical Medical Assisting Procedures
Montachusett Regional Vocational Technical School
Fitchburg, MA2012
Property Damage Mitigation Certificate - Property Damage Mitigation
Property Restoration Technician
Salem, NH2009
Medical Office Administration Certificate - Medical Office Administration
M.O.C. Learning Center
Fitchburg, MA1997
Skills
- Complex problem solving
- Documentation Review
- Internal Auditing
- Quality Control Processes
- Seasoned in conflict resolution
- Strong organizational skills
- Effective time management
- Strong communication skills
- Proficient in customer account software
- Multi-channel contact center software
- Reporting and documentation
- Adaptive team player
- Medical Terminology
- Proficient with Microsoft Office Suite
- Healthcare billing proficiency
- Expert in customer service relations
Certification
Associate Certified Fraud Examiners - ACFE
Timeline
SIU Prepay Investigator
Optum
09.2020 - 05.2024
Senior Quality Assurance Auditor
United Healthcare
09.2016 - 09.2020
Senior Customer Service Representative
United HealthGroup
09.2013 - 09.2016
Owner/Corporate Financial Officer
Kasmik LLC DBA Neighborhood Property Services
01.2008 - 01.2014
Medical Biller / Accounts Receivable
Monadnock Community Hospital
03.2002 - 04.2008
Medical Biller
HealthAlliance Hospital
01.1997 - 03.1999
Fraud Case Info Share CEU
National Healthcare Anti-Fraud Association
Associate of Science - Criminal Justice
NHTI-Concord's Community College
Certified Clinical Medical Assistant - Clinical Medical Assisting Procedures
Montachusett Regional Vocational Technical School
Property Damage Mitigation Certificate - Property Damage Mitigation
Property Restoration Technician
Medical Office Administration Certificate - Medical Office Administration
M.O.C. Learning Center
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