Summary
Overview
Work History
Education
Skills
Websites
Certification
Timeline
Generic
Tiffany Wright

Tiffany Wright

Houston,TX

Summary

Professional investigator with extensive experience in leading comprehensive investigations and resolving complex cases. Proven ability to collaborate effectively with teams and stakeholders, ensuring accurate and timely results. Known for reliability and adaptability, with expertise in investigative techniques and legal compliance.

Overview

15
15
years of professional experience
1
1
Certification

Work History

Sr. Investigator

United Healthcare
01.2023 - Current
  • Led complex investigations into healthcare fraud and abuse, ensuring compliance with regulatory standards.
  • Ensure timely completion of required referrals, both internal and external, as directed.
  • Resolved complex cases with diligent research, analysis, and collaborative problem-solving efforts.
  • Ensured compliance with all federal, state, local laws/regulations during the course of conducting investigations.
  • Participated in ongoing professional development opportunities related to the field of investigation keeping up-to-date on current trends and techniques.
  • Developed comprehensive reports that effectively communicated investigation findings to stakeholders and decision makers.
  • Developed and implemented investigative strategies to identify patterns in fraudulent activities.
  • Analyzed claims data to identify patterns indicative of fraudulent activities, enhancing detection processes.
  • Maintained detailed records on all investigations conducted, ensuring accuracy and adherence to legal requirements.
  • Presented findings to senior leadership, providing actionable insights for policy development and preventive measures.

Investigator

United Healthcare
01.2019 - 01.2023
  • Conducted onsite and desktop investigative audits targeting potential Pharmacy Fraud Waste and Abuse (FWA). Reviewed and synthesized complex federal statutes, regulations, documents, and communications to provide clear and concise information to senior leaders, business owners, and other key stakeholders.
  • Collected data, coordinate, and develop reports, maintaining internal and external documentation in tracking tools.
  • Host and lead discussions to educate and prepare stakeholders focusing on audits that highlighted fraud and regulatory changes.
  • Prepared detailed reports summarizing findings, recommendations, and action plans for senior management review.
  • Utilized advanced investigative tools and software to support data collection and analysis efforts.
  • Collected, analyzed and interpreted information, documentation, and physical evidence associated with investigations.

Appeals & Grievance Representative

United Healthcare
01.2016 - 01.2018
  • Researched and addressed inquiries, requests, and complaints from regulators, business partners, and members. Efficiently resolved high-profile provider deficiencies and documented grievance determinations with appropriate response letters. Ensured timely completion of special projects.
  • Spearheaded initiatives in analyzing and resolving written Department of Insurance complaints and complex or multi-issue provider complaints submitted by members and physicians/providers.
  • Collaborated with other departments (i.e., clinical, claims, billing, etc.) to gather additional information to answer member questions or to resolve escalated issues.
  • Proactively maintained heavy caseloads of assigned appeals, researching, and resolving provider claim disputes, and meeting process deadlines in accordance with policies and regulations.
  • Managed client inquiries, ensuring timely resolutions and high satisfaction levels.
  • Collaborated with cross-functional teams to streamline communication processes within the organization.
  • Increased customer satisfaction by addressing and resolving complaints in a timely manner.
  • Handled customer complaints quickly and professionally to restore customer confidence and prevent loss of business.
  • Managed customer inquiries, delivering accurate information and resolving issues efficiently.
  • Collaborated with cross-functional teams to streamline claims processing workflows.

Lead Pharmacy Technician

United Healthcare
01.2011 - 01.2016
  • Reviewed pharmacy claims for accuracy and compliance, resolved benefit discrepancies, and supported issue tracking and reporting. Managed prior authorizations and analyzed medical records for appeals.
  • Successfully compiled departmental communications using existing templates and systems, providing appropriate attachments, and/or fax determination letters to physician(s), specialty pharmacy(s) and members.
  • Initiated outbound calls to providers regarding appeals and grievances, and authorization status.
  • Managed daily case review assignments, with a high emphasis on quality and documents findings with the case tracking system.

Education

Bachelor of Science Degree - Healthcare Administration

California Coast University
Santa Ana, CA
01.2011

Associate in Arts Degree -

Houston Community College
Houston, TX
05.2009

Skills

  • Intermediate Knowledge of FWA Investigational Experience
  • Drug Classification & Safety
  • Medicare, Medicaid & Insurance Claims Processing
  • Team Coordination
  • Care Planning Time Management
  • Team Engagement
  • Cross Functional Leadership
  • Communication Skills
  • Quality Assurance
  • Certified Pharmacy Technician
  • Technical Snapshot: Microsoft Office Suite, RXClaims/AS400, Microsoft PowerPoint
  • Investigation skills
  • Intelligence gathering
  • Expert interviewing skills
  • Claims research

Certification

  • Pharmacy Technician Certification Board - Certified Pharmacy Technician
  • Texas State Board of Pharmacy - Registered Pharmacy Technician

Timeline

Sr. Investigator

United Healthcare
01.2023 - Current

Investigator

United Healthcare
01.2019 - 01.2023

Appeals & Grievance Representative

United Healthcare
01.2016 - 01.2018

Lead Pharmacy Technician

United Healthcare
01.2011 - 01.2016

Bachelor of Science Degree - Healthcare Administration

California Coast University

Associate in Arts Degree -

Houston Community College