Nicholas Goldup
Special Investigator Fwa @CDPHP
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WORK HISTORY
Special Investigator Fwa @CDPHP
Investigation and analysis of complex insurance cases to detect fraud and abuse, both external and internally. • Prepare Documents and case reports, utilizing available resources to identify suspicious billing patterns and trends. • Conduct interviews of providers, members, and person/persons with knowledge of the matter under investigation. • Assist in performing audits of providers’ claim submissions to assure services rendered and billed correspond with members’ medical records. • Identify violations of CDPHP providers ‘and/or members’ contracts/agreements, State and Federal law pertaining to the health care field. • Assist in negotiating favorable financial settlements on behalf of CDPHP or in preparation of civil suit. • Assist in the creation of quarterly and annual reporting provided to various oversight agencies. • Compose and present Fraud, Waste and Abuse Training program to New Employees as well as quarterly updates and year end employee training. • Attend regular and annual trainings necessary to obtain and maintain accreditation as an Accredited Health Care Fraud Investigator. • Ability to explain and interpret evidence in a clear and precise manner to law enforcement authorities. • Represent the company and testify in Federal and State court proceedings. • Knowledge of complex contracts with healthcare systems, large medical groups, hospitals, ancillary providers, individual practitioners, and members for CDPHP Commercial, Medicare, and Medicaid lines of business. • Strong analytical decision making, problem solving, communication (oral and written) skills. • Manage and prioritize case load with limited supervision. • Meet regularly to present and discuss cases with various departments and outside regulatory agencies.
EDUCATION
Hudson Valley Community College
Associate's degree, Business Administration and Management, General
SKILLS
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