Tawny Smith
Senior Healthcare Fraud & Payment Integrity Investigator | $2.1M Improper Payment Recovery | CPC, CRC | Medicare & Medicaid FWA Investigations
- Role
- Behavioral Health Coding Quality Analyst Fwa, Audit & Recovery at Optum
- Location
- Little Rock, AR, US
- LinkedIn followers
- 500 followers
About Tawny Smith
Key Achievement: Identified and recovered $2.1M in improper payments in 2025 across Medicare, Medicaid, and commercial healthcare programs through fraud detection, coding audits, and payment integrity investigations.Healthcare fraud and payment integrity professional with extensive experience identifying fraud, waste, and abuse (FWA) across Medicare, Medicaid, and commercial healthcare programs. I specialize in detecting improper billing patterns, conducting coding audits, and performing investigative claims analysis to protect healthcare program integrity. In my current role with OptumInsight, a division of UnitedHealth Group, I conduct behavioral health coding audits and payment integrity investigations that identify billing irregularities and compliance risks. In 2025, I identified and recovered $2.1M in improper payments through detailed claims analysis, documentation reviews, and fraud detection efforts across Medicare, Medicaid, and commercial programs. My background combines fraud investigation, coding compliance, and analytics-driven claims analysis. As a Certified Professional Coder (CPC) and Certified Risk Adjustment Coder (CRC) with Lean Six Sigma Black Belt certification, I bring a strong understanding of CMS regulations, provider billing practices, and healthcare compliance requirements. I have experience investigating provider billing patterns, conducting investigative interviews, and preparing case documentation to support legal, compliance, and regulatory reviews. Areas of expertise include: • Fraud, Waste & Abuse (FWA) Investigations • Payment Integrity & Improper Payment Recovery • Healthcare Fraud Detection • Claims Analysis & Provider Billing Reviews • Behavioral Health Coding Audits • Risk Adjustment Validation • Medicare & Medicaid Compliance I am passionate about strengthening healthcare program integrity through data-driven investigations, collaboration with compliance and legal teams, and proactive fraud detection strategies. Open to connecting with professionals working in healthcare fraud investigation, SIU operations, payment integrity, and program integrity initiatives.
Experience
Behavioral Health Coding Quality Analyst Fwa, Audit & Recovery
May 2024 — Present · US
Identified and recovered $2.1M in improper payments in 2025 while maintaining 100% quality and productivity.Conduct FWA-focused coding audits and retrospective investigations on behavioral health claims. Review suspicious and high-risk claims to determine medical necessity, coding accuracy, and reimbursement appropriateness. Identify aberrant coding and billing patterns through data analysis and utilization review. Apply CPT, ICD-10, HCPCS, Revenue coding guidelines, and Centers for Medicare & Medicaid Services (CMS) regulations. Develop audit findings, documentation, and case summaries to support SIU investigations and recovery actions. Collaborate with internal teams to support overpayment identification, recovery efforts, and provider education.
Education
University of Arkansas - Pulaski Technical College
Associate of Applied Science , Business Office Supervision & Management
American Academy of Professional Coders
Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), Medical Coding
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