Karen Dowdy

About Karen Dowdy

Key Skills • Excellent oral and written communication skills, including conflict…

Experience

1. Fraud Specialist and Administrative Action Coordinator

   Qlarant

   May 2021 — Present

   Plan, design and carry out investigations of Medicare fraud by focusing on identifying deviant claims patterns and fraud indicators• Work as part of a team investigators, data analysts, statisticians, medical professionals, etc to develop proactive fraud detection projects and to investigate specific reactive cases• Identify national fraud trends and prepares fraud alerts and vulnerability reports to advise other organizations of potential fraud risks• Determine and implement appropriate administrative / legal remedies based on the findings of investigative efforts including revocation of billing privileges, suspension of payments, and referral to the OIG, FBI, AUSA or other Federal/ State agency for criminal/ civil proceedings • Work with OIG, FBI, AUSA and other Federal/State agents throughout case building and court proceedings• Draft referrals to QIO when patient harm has been established• Draft requests for suspension resulting in suspension of the provider’s billing privileges and reduced loss to the Medicare Trust Fund as well as revocations, removing fraudulent providers from the program entirely• Analyze medical review determinations• Interpret data to identify aberrant billing • Conduct interviews with Medicare/Medicaid patients, and Medicare/Medicaid providers and staff • Consultant to other investigators on evaluating investigations for appropriate direction and resolution in a mentor capacity• Closed numerous investigations, including drafting educational letters apprising Medicare providers of relevant regulations; identify and write for overpayments for recoupment • Correspond with providers’ attorneys including formal requests and rebuttal responses • Identify and participate in onsite audits of Medicare providers and operate as Lead Onsite Investigator

Education

• Middle Tennessee State University

  Bachelor's degree

Skills

• Criminal Investigations
• Government
• Investigation
• Customer Service
• Fraud
• Evidence
• Interviewing Skills
• Data Analysis
• Conducting Interviews
• Policy
• Claim
• Risk Assessment
• Insurance
• Fraud Detection
• Sales
• Leadership
• Criminal Justice
• Interviews
• Background Checks
• Investigative Research
• Medicare
• Health Care Fraud
• Claim Investigation