Shane Tiernan
Bountiful
Summary
Dynamic leader with extensive experience at Molina Healthcare, driving operational excellence and achieving over $100 million in financial recoveries. Expert in data analytics and strategic planning, fostering team productivity and morale. Proven track record in managing large-scale projects and enhancing organizational development through innovative solutions and effective communication.
Forward-thinking Senior Manager adept at managing teams of 103 direct indirect employees with five direct reports to accomplish challenging objectives. Imparts clear vision to guide cohesive, high-performing teams.
Versatile Director specializing in auditing, compliance, and skilled at planning, implementing and overseeing key improvements to drive business growth and efficiency. History of cultivating an open culture with free exchange of information. Pursuing new professional challenges with a growth-oriented company.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Associate Vice President
Molina Healthcare, Inc.
07.2018 - Current
- Responsible to onboard multiple vendor solutions for large scale auditing claims for potential fraud, waste, and abuse.
- Annual financial recoveries and cost avoidance exceeding $100 million.
- Managed large-scale projects and introduced new systems, tools, and processes to achieve challenging objectives.
- Executed appropriate staffing and budgetary plans to align with business forecasts.
- Provided strong leadership to enhance team productivity and morale.
- Conducted performance evaluations, compensations and hiring to maintain appropriate staffing requirements.
- Implemented and developed operational standards, policies and procedures.
- Boosted team member productivity by enhancing performance monitoring and instituting motivational approaches.
- Reviewed and analyzed reports, records and directives to obtain data required for planning department activities.
- Held monthly meetings to create business plans and workshops to drive successful business.
- Observed each employee's individual strengths and initiated mentoring program to improve areas of weakness.
- Implemented innovative programs to increase employee loyalty and reduce turnover.
- Reduced operational risks while organizing data to forecast performance trends.
- Reported team results to compliance and corporate leadership on a regular basis.
Senior Fraud Investigator
LA Care
03.2018 - 07.2018
- Responsible to build the pharmacy audit component for SIU.
- Presented cases to state auditors and law enforcement for prosecution
- Analyzed large amounts of data to find patterns of fraud and anomalies.
- Reviewed reports and individual transactions which appeared suspicious to uncover possible fraudulent activity.
- Tracked fraud cases and monitored trends to develop strategies for prevention.
- Evaluated customer data to identify and prevent fraudulent activities.
- Analyzed financial statements to identify discrepancies, irregularities and fraudulent activity.
- Interviewed witnesses thoroughly, asking appropriate questions to ascertain critical details about each case.
- Reviewed transactions and receipts to identify any suspicious activity.
- Collaborated with team members to discuss fraud trends and brainstorm methods to combat this type of crime.
- Participated in team projects, demonstrating an ability to work collaboratively and effectively.
Associate Director, Law Enforcement Liaison
Purdue Pharma
02.2013 - 03.2018
- Provided training to law enforcement agencies and associations on pharmaceutical identification and investigation of drug diversion.
- Provided pharmacy safety instruction to open and closed-door pharmacies in relation to crime prevention and reaction.
- Assisted law enforcement agencies in obtaining grants to fund pharmaceutical crime investigations, tracking, and use of placebo medications in undercover operations.
- Field support for Sales and Medical Liaisons to resolve specific issues related to controlled substance prescribing by clinics, hospitals, and prescribing practitioners. This position required in-depth knowledge of professional licensing and scope-of-practice regulations throughout my area of responsibility. My territory consisted of all states west of Colorado, including Hawaii and Guam.
- Presented training for continuing medical education to health care practitioners on issues regarding lawful prescribing and drug dispensing under the United States Code of Federal Regulations.
- Regularly provided instruction to health care groups, hospital systems, and small medical practices on risk management and risk mitigation. Training was also provided to chain pharmacies and pharmacy staff members about internal and external security issues.
Deputy Director, Utah Insurance Fraud Division
State of Utah, Department of Insurance
02.2002 - 02.2013
- Analyzed reports of all forms of insurance fraud encompassing staged automobile accidents, healthcare fraud, Worker’s Compensation fraud, durable medical equipment fraud, and drug diversion.
- Contributed to formation of FBI Health Care Fraud Task Force emphasizing prevention of illegal diversion of controlled substance pharmaceuticals.
- Deputized as a Special Deputy United States Marshal.
- Managed various, complicated healthcare fraud investigations.
- Executed search warrants, conducted arrests, and prepared cases for prosecution to county, state, and United States Attorney’s offices.
- Regularly delivered testimony in criminal and regulatory proceedings and addressed media inquiries.
- Implemented more open communication with private insurance carriers, which greatly increased the number of health care fraud cases investigated and prosecuted by the Division.
- Conducted numerous speaking engagements as a representative of the Fraud Division to law enforcement agencies, industry professionals, pharmacies, and hospital administrators and staff.
- Maintained the highest statistics in my division for arrests, financial restitution, search warrants, and cases completed.
- Supervised the investigation staff for the Division, maintained the evidence room, division equipment resources, and implemented policy and procedures.
- Formed the Intermountain West Pharmaceutical Narcotic Enforcement Team (IRxNet) which was comprised of local, state, and federal officers. The mission of this unit was to respond to the rising problem of narcotic diversion. Its specific purpose was to target those profiting from the street sales of pharmaceutical narcotics.
Investigator II
State of Utah, Department of Occupational & Professional Licensing
11.1998 - 10.2002
- Collaborated with federal agencies on investigations.
- Conducted thorough face-to-face interviews with employers, families, neighbors, friends, and suspects, and documented investigative findings.
- Conducted interviews with witnesses and clients.
- Documented findings and prepared detailed reports.
- Carefully documented statements, observations, and evidentiary materials.
- Prepared case reports from allegations, transcripts of interviews and physical evidence.
- Collected information pertaining to criminal proceedings and performed investigations to resolve cases.
- Collected crime scene evidence, examined bodies, and investigated secondary locations to build detailed cases based on sound evidence handling practices.
- Delivered calm, professional testimony to support case evidence, establish timelines, and offer law enforcement expertise.
- Oversaw criminal cases, coordinated investigations, and prepared evidence and investigators for court cases.
- Conducted multi-scope research into suspects to determine criminal activities and suspect operating environments.
- Conducted investigations of narcotic drug diversion by doctors, nurses, and allied medical providers from hospitals and clinics. Investigated drug shortages from pharmaceutical facilities and investigated fraudulent medical billings by private practitioners.
Education
Bachelor of Science - Criminal Law
Weber State University
Ogden, UT06-1999
Associate of Science - Criminal Justice
Salt Lake City Community College
Salt Lake City, UT06-1997
Skills
- Department leadership
- Organizational development
- Administrative oversight
- Budget preparation
- Operations management
- Corporate communications
- Budget oversight
- Strategic planning
- Cross-functional team leadership
- Data analytics
- Budget administration
- Market analysis
- Database development
Certification
Accredited Health Care Fraud Investigator (AHFI)
Timeline
Associate Vice President
Molina Healthcare, Inc.
07.2018 - Current
Senior Fraud Investigator
LA Care
03.2018 - 07.2018
Associate Director, Law Enforcement Liaison
Purdue Pharma
02.2013 - 03.2018
Deputy Director, Utah Insurance Fraud Division
State of Utah, Department of Insurance
02.2002 - 02.2013
Investigator II
State of Utah, Department of Occupational & Professional Licensing
11.1998 - 10.2002
Bachelor of Science - Criminal Law
Weber State University
Associate of Science - Criminal Justice
Salt Lake City Community College