Investigator Resume

1. Resume
2. Insurance Resume
3. Investigator Resume

Investigators are employed in all industries to prevent scams in business or detect the alleged frauds. They work for private clients, government agencies, corporate world as well as insurance industry to identify cases of fraud focused on obtaining monetary gain. The health insurance industry provides different types of policies to customers to help in medical emergencies for the policy holder or a family member. However, sometimes the claimant presents exorbitant bills to the insurance agency to get substantial benefits. Furthermore, hospitals levy surplus charges by not following standard regulations adding to the patient's treatment cost. These are cases related to frauds in healthcare. To keep these issues in check, the insurance agencies employ investigators who verify the case before approving claims. A health insurance investigator has exceptional research abilities, is responsible for collecting thorough information about the treatment, has expertise in conducting interviews, analytical abilities and good people skills. These investigators maintain close relations with law officers, and assist to identify fraud claims by following investigative procedures. A bachelor's degree in law or relevant field is required. If you are interested in working for this profile, draft your resume by referring to the sample given below.

Investigator Resume Sample

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Keri A. Cluff
455 Northwest Boulvard
Washington, DC 20024
Phone: 577-726-9371
Email: keri.cluff@anymail.com

Career Summary:

Detail-oriented and certified professional with extensive knowledge about the procedure followed in investigating fraud cases. An experienced Health Insurance Investigator with ability to collect concrete evidence, analyze submitted documents, and prepare investigation reports on claims. Adept at doing sound research, and conducting interviews with excellent communication skills.

Summary of Skills:

• Extensive experience in identifying fraudulent cases, and investigating illicit activities
• Sound knowledge about investigative methods, and current industry practices
• Familiar with medical terminologies and basic knowledge about overall treatment cost for various illnesses
• Capable of drawing sound conclusions by doing field investigation, and researching facts
• In-depth information about the insurance laws, and ability to work under pressure
• Resourceful with ability to handle multiple tasks according to priority
• Proficiency with Microsoft Office Suite and managing database system
• Good communicator and a team player

Work Experience:

Health Insurance Investigator
AFLAC Insurance Corporation, Washington, DC
September 2017 – Present

• Responsible for doing field investigations in medical cases involving car accidents, and collecting evidence from the location
• Performing duties related to hospital visits to understand patient progress, and overall treatment plan
• Reviewing submitted documents, and conducting thorough interviews of claimants
• Coordinating with the hospital to understand billing procedures for the treatment, and comparing it to the claims submitted by the patient's family member, or caretaker
• Testifying and presenting solid evidence in court procedures for fraud insurance claimants
• Responsible for obtaining medical reports, documents, and lab test reports to support the evidence
• Preparing and submitting detailed reports covering all phases of investigation to senior management for further approval or rejection

Health Insurance Investigator
AmeriHealth Insurance, Washington, DC
April 2015 – August 2017

• Reviewed documents submitted by claimants, and analyzed the data as a part of the investigative process
• Interviewed medical practitioners to determine the severity of the disease before passing the medical claim
• Proactively performed research on the internet to understand the treatment method, and analyzed the billing patterns of healthcare settings
• Identified opportunities for improvement by initiating regular audit process, and recommended system enhancement to upgrade investigative process for better outcome
• Represented the company for settling claims
• Established and maintained professional relationships with legal officers, law enforcement officers, and police department to get assistance for conducting investigations

Insurance Claims Analyst
AmeriHealth Insurance, Washington, DC
July 2013 – March 2015

• Conducted proper research, and passed prompt resolution for cases with disputed claims
• Took responsibility to verify the documents submitted by the claimants, and coordinated with the healthcare facility to establish the facts
• Communicated with appropriate departments to submit reports about the claims made by the concerned person after interpreting policy services
• Performed detailed analysis of pending cases to determine issues affecting claims
• Updated and maintained company's database to facilitate correct tracking and reporting of disputed claims
• Attended team meetings to improve claims closing rate by identifying the fraud cases, and recommended possible solutions to the department
• Assisted policy holders with different coverage or claims related questions

Education:

• Associate Degree in Criminal Justice
  Georgetown University, Washington, DC
  2010

• Diploma in Insurance Services
  Georgetown University, Washington, DC
  2012

Certification:

• Accredited Healthcare Fraud Examiner, 2015
  Certified Insurance Fraud Examiner, 2013
  

Reference:

On request.