Nicole Ralston

40 Hours/Week

$77,000/Year

• Investigates potential instances of fraud within payment integrity and financial recovery.
• Analyzes customer account transactions to detect unusual activity and take appropriate action.
• Works cooperatively with business lines to establish procedures for identifying suspicious customer transactions.
• Interviews suspects and potential identity theft victims.
• Reviews and analyzes Investigative referral forms regarding potential fraud.
• Monitors data and customer profiles for suspicious activity
• Responsible for ongoing monitoring of accounts and transactions to help identify unusual activity.
• Creates clear and concise feedback that supports case direction.
• Skilled at identifying normal and suspicious transactional activity as well as analyzing transactions identified by Fraud systems
• Reviews of subpoenas received by Humana
• Investigates all fraud typologies, included but not limited check fraud, identity theft, payment fraud
• Monitors fraud prevention reports and/or reviews and resolves claims to address potentially fraudulent activity and reduce possible losses
• Maintains company fraud database records
• Generates appropriate alerts for further as necessary
• Assist in implementation of screening detection methods, such as training and instruction manuals
• Utilizes internal systems to review customer and transactional information, conduct public data searches and utilize internal guidance to make such determinations.
• Analyzes suspicious activity on customers' accounts and researches history for customer activity.
• Responsible for reviewing information and transactional activity and making recommendations to close or escalate alerts for further review.
• Prepares accurate reports for internal and external reporting requirements within prescribed timeframes.
• Ensures proper record-keeping of data collected and analyzed
• Provides case summary and recommendations based on case findings
• Work cooperatively with business lines to establish procedures for identifying suspicious customer transactions.
• Reduced fraudulent activity by implementing effective fraud detection strategies and tools.
• Collaborated with law enforcement agencies to resolve complex fraud cases, leading to successful prosecution of offenders.
• Identified potential risks by conducting thorough investigations and analyzing transaction patterns.
• Improved company-wide security measures through development and implementation of fraud prevention policies and procedures.

40 Hours/Week

$69,000/Year

• Evaluate and investigate fraud, abuse complaints, and billing discrepancies on insurance claims
• Document each phase of investigation using tracking tools, spreadsheets & internal systems
• Made recommendations based on investigative findings.
• Conducted thorough research and analysis, providing valuable insights for client decision making.
• Improved client satisfaction by effectively managing multiple projects and consistently meeting deadlines.
• Analyzed problematic areas to provide recommendations and solutions.

40 Hours/Week

$60,000/Year

• Identify and investigate complex and sensitive internal fraud cases
• Analyze large volumes of data from disparate sources to identify outliers, discreet patterns, impact analysis, red flag behaviors, and potentially fraudulent activities
• Responsible for independently identifying and developing enterprise-wide specific investigations and initiatives that may impact more than one carrier, line of business, and/or state.
• Improved case resolution times by streamlining investigation processes and optimizing resource allocation.
• Developed and maintained strong working relationships with law enforcement agencies for collaborative fraud investigations.
• Conducted comprehensive fraud risk assessments, identifying potential vulnerabilities and recommending appropriate mitigation measures.

40 Hours/Week

$60,000/Year

• Adjudicating claims/acquiring pertinent information related to specific cases
• Completed required investigations on referred files in a timely manner
• Investigating & analyzing internal system data to detect fraud
• Communicating & cooperating with necessary parties (insured, witnesses, agents, law enforcement, vendors etc.)
• Improved case resolution rates by conducting thorough investigations and utilizing effective interviewing techniques.
• Enhanced department efficiency with streamlined processes for evidence collection and documentation.

.40 Hours/Week

$60,000/Year

• Analyze claims data and other internal tools/resources for fraud research.
• Conduct internal complex investigations.
• Assists in development of policy and/or procedures to prevent loss of company assets.
• Investigate any potentially fraudulent claims with focus on thoroughness quality and cost control
• Reduced financial losses due to effective identification and mitigation of potential risks in the portfolio.
• Streamlined risk reporting procedures for improved communication with stakeholders and senior management.

40 Hours/Week

$50,000/Year

• Responsible for completing quality assurance reviews within Operations and other internal departments
• Review all necessary documentation and claim information to determine processing accuracy.
• Tested finished products to perform quality assurance and identify discrepancies.