Victoria Thomas-Plasencia
Plantation,FL
Summary
Fraud investigation professional prepared to bring high standards and results-driven approach to role. Known for impactful fraud detection and prevention efforts, contributing to organizational integrity. Emphasizes team collaboration and adaptability to ensure comprehensive fraud mitigation. Expertise in risk analysis and strategic problem-solving.
Overview
21
21
years of professional experience
Work History
Senior Fraud Investigator
Elevance Health
08.2024 - Current
- Conducted regular audits of coded records to ensure compliance with established standards and make appropriate adjustments as needed based on findings.
- Maintained compliance with federal regulations, including HIPAA privacy rules, by implementing strict data handling procedures within the department.
- Monitored changes in coding regulations to provide recommendations for compliance.
- Researches new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends and changes in laws/regulations.
LPN
Kelly Staffing
10.2019 - 08.2024
- Long term care, Diabetic care, Memory care, Hospital
Fraud Investigator
United Health Group (Optum Health)
10.2010 - 10.2019
- Review Provider medical records for billing accuracy
- Review patient medical plan policy for benefit coverage
- Encoder Pro, COSMOS, CSP, GLHP, FACETS Unison claims platforms
- Detects and PICTS experience
Hospital Bill Auditor/Clinical Appeals
United Health Group/Ingenix (Hospital Bill Audit Services)
01.2008 - 10.2010
- Company Overview: Special Projects
- Audit medical records for coding accuracy
- NICU Project, AIP & Standard Implant Review, ER Review Project, Assistant Surgeon Review, as well as DRG Review Project
- Conduct conference calls with facilities to start the appeal process
- Review & interpret contracts between facility and insurer
- ICD-9 and InterQual experience
- Microsoft word, excel, access
- Special Projects
LPN Telemetry/ICU Unit
Kindred Hospital
03.2004 - 06.2008
- Company Overview: (Ft
- Lauderdale)
- Total patient care of patients with complex medical conditions in an acute hospital setting
- Ventilator weaning, cardiac and renal dysfunction
- (Ft
- Lauderdale)
Education
Associate of Arts -
Broward College
Fort Lauderdale, FL01-2021
Licensed Practical Nurse - Nursing
Sheridan Technical Center
01-2004
Affiliations
- American Health Information Management Association
Timeline
Senior Fraud Investigator
Elevance Health
08.2024 - Current
LPN
Kelly Staffing
10.2019 - 08.2024
Fraud Investigator
United Health Group (Optum Health)
10.2010 - 10.2019
Hospital Bill Auditor/Clinical Appeals
United Health Group/Ingenix (Hospital Bill Audit Services)
01.2008 - 10.2010
LPN Telemetry/ICU Unit
Kindred Hospital
03.2004 - 06.2008
Associate of Arts -
Broward College
Licensed Practical Nurse - Nursing
Sheridan Technical Center
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