MacDalia Alia Dormeus
Auditor Siu Investigator @Evolent
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WORK HISTORY
Auditor Siu Investigator @Evolent
US
As an investigator, I serve as a key contributor to fraud detection and prevention efforts, ensuring compliance with federal and state regulations. I utilize preliminary data to develop, conduct, resolve, document, and report on incidences that suggests potentially fraudulent or abusive behavior.Responsibilities included but not limited to:• Investigate to prevent payment of fraudulent claims committed by insured\'s, providers, claimants, customer members, etc.• Research and prepare cases for clinical and legal review.• Document all appropriate case activity in tracking system.• Effectively manage use of outside resources and vendors to perform activities necessary for investigations.• Managed relationships with internal and external stakeholders to optimize investigative resources and improve case resolution efficiency.• Conduct thorough investigations into suspected fraud and abuse, ensuring compliance with federal and state regulations. • Collaborated with law enforcement agencies to facilitate the recovery of funds lost due to fraudulent activities. • Developed and delivered educational programs that enhanced fraud detection and prevention efforts, minimizing company losses.
EDUCATION
Florida State College at Jacksonville
Associate's degree, Business Administration, Management and Operations
ABOUT MACDALIA ALIA DORMEUS
At Evolent, I work to safeguard program integrity by preventing and addressing fraudulent, wasteful, or abusive practices. With over ten years of experience in fraud detection and regulatory compliance, I leverage data analysis and investigative techniques to ensure adherence to federal and state regulations. My contributions include resolving complex cases, documenting findings, and facilitating collaboration with clinical and legal teams to protect organizational assets. Previously, I contributed to fraud, waste, and abuse investigations at Genpact, UnitedHealth Group and Citibank. There, my expertise spans in regulatory compliance, fraud detection, appeals, CTM and case management. Known for a detail-oriented approach to investigations in healthcare and banking regulatory processes, I remain motivated by the opportunity to contribute to program and operational excellence.
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