Marian Peguero, JM

Conducts investigations requiring the use of various data-driven mechanisms to initiate investigations, identify subjects, and develop cases for future action, including referral to law enforcement, education, overpayment recovery, and other administrative corrective actions per Medicare guidelines, rules, and regulations. Performing field investigative work to identify potential Fraud, Waste, and Abuse by providers billing the Medicare Program for the entire Southeast Unified Program Integrity Contractor (SE-UPIC) jurisdiction (TN, NC, SC, GA, AL, FL, PR, and VG), responsible for: • Development of investigations from the regulatory framework to identify infringements of Medicare guidelines and regulations, including statutory violations of the False Claims Act, Anti-Kickback statute, and Local Coverage Determination (LCD), among other rules geared to identify and deter the potential for Fraud, Waste, and Abuse of Medicare Funds. • Identify and present issues of concern, citing regulatory violations, alleging schemes to defraud the Government by adequately interpreting the laws and regulations and applying them to investigative findings. • Evaluation of comprehensive Medicare Claims data to identify aberrancies such as overutilization, upcoding, and other schemes to defraud the Medicare Program, ensuring the investigation's legal viability by understanding applicable laws and regulations.

Conducted review of referrals incoming from all external entities, including: • Medicare Administrative Contractor (MAC), Medicare Drug Integrity Contractor (MEDIC), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), Centers for Medicare & Medicaid Services (CMS), Dept. of Health and Human Services (DHHS), other Integrity contractors with jurisdiction in the NE, SW and MW, W for the entire Southeast Unified Program Integrity Contractor (SE-UPIC). • Record keeper for an average of over 200 complaints and referrals a month for the entire jurisdiction (WV, VA,TN,NC,SC,GA,AL, FL, PR and VG). • Executed initial investigations screening and identified potential Fraud, Waste, and Abuse by providers billing the Medicare and Medicaid Program. • Performed in-depth evaluation of all pertinent documentation, Data analysis, and writing of the initial investigative reports. • Responsible for referral assignments for the various Investigations Field Teams, ensuring timeliness and accountability of every lead. • In charge of reporting IER workload to the Management team for the SE-UPIC.

Provide administrative support to Fraud Investigations managers. · Assist Fraud Investigators with the assigned investigations as it relates to fraud, waste and abuse. In addition to administrative duties to include scanning documents, assisting investigators and maintenance of investigation file folders, and maintain customer service incoming call records in UCM / WMM and mass mailing projects. · Coordinator of the Complaints Committee. Screening and tracking all incoming complaints to discuss in the monthly meeting to assign as a lead to investigative teams or return to the MAC after following the IO creating process in WMM. Creator of temples of letters to the MAC and Supported Modification process for JOA Appendixes with PGBA. · Screening of Referrals and complains prior to presenting to Investigations Managers to determine PECOS status, Zone Restrictions, prior cases based after running BO reports and identifying Administrative actions taken among other Important as it may relate to the predicate basis and workload criteria. · Responsible for the Probe Review Mailbox by coordinating a prompt and accurate response to the MAC in regards to TPE inquiries. ·Assist the Investigations Team, BSA and DRA teams with different projects.

• Managed 30-100 calls per day (inbound and outbound) for Medicaid, dental/vision plans, among other product sales complying with local and federal laws. • Make any updates for members when requested by them as far as PCP changes, Address change, Plans, Case Managers, nurses, etc. • Answer multiple incoming calls including multitasking inquiries from members in a professional manner. • Work with members claims, EOB, or statements by reaching out to Providers or HSO. Create and coordinate Pre-Authorizations for any medical procedures or medications. • Document every call as well as file any Grievance or Appeals.

Assisted Supervisors and Managers on the relocation of the call center out the state of Massachusetts, providing assistance implementing standard procedures, training and hiring. • Assisted manager with daily project operations, including volume, volume real-time monitoring and reassignment of agents to growing queues, projections and appropriate staffing levels. • Supervised 35 agents assisting incoming calls from members and prospective members. Respond accurately to member calls related to, member eligibility, premium billing, eligibility issue and enrollment. • Lead in charge of supervisor escalated cases to ensure members are being provided with accurate information and re enforcing company policies, by reaching out to other departments to ensure cases are being worked. • Processed attestation of no income, attendance reporting, Spanish queue overloads and supervisor calls. • Provided representatives coaching and follow ups due ombudsman and management requests.

Processing associate for items as residency, immigration, identity verification and ACA application helping individuals applying for coverage and benefits by reviewing their details for determination and eligibility for subsidy and public benefits programs, for health assistance programs. Strong understanding of health care enrollment process systems and benefits determination systems, for and state sponsored programs (SSP). Knowledge of Medicaid systems as Health Information Exchange (HIE), and Health Insurance Exchange (HIX) programs MCE and other Medicaid systems. • Founding associate in Department of Processing and verifications (DV&P). • Assisted creating and implementing process for the processing of regular daily basis requests, items as residency, immigration, and identity verification also for especial projects handed by the client. • Provided department’s daily processing reports to management and State Governor. • Facilitated resolution of issues that threaten delivery dates of projects included within the program, as they relate to other work streams and/or other projects included in the program. • Ensured that there was efficient allocation of common resources and skills within the projects of the program portfolio. • Assisted Project Managers and other Program Managers in the strategic application of technical knowledge to address business problems/challenges. • Helped creating processes and reporting to complete a backlog of 100,000 member residency, immigration, and identity verifications complying with a client’s set deadline of 3 months.

Function as the front-line contact for all members by responding to a high-volume of incoming calls from members and prospective members. Respond accurately to member calls related to, member eligibility and managed care status, program guidelines and procedures. • Assisted educating and instructing members on routine policy matters such as, and not limited to: eligibility and enrollment, claims and premium billing, managed care, and covered service, special programs. • Performed accurately all data entry functions to recent member or provider activity-/transactions. • Facilitated the resolution of clerical and non-clerical issues related to member compliance/participation according to established policies and protocols.

Service and distribution of 3D CAD solutions to the industry, Authorized SolidWorks Reseller and provider of technical support. Function as person in charged of the portfolio of clients and prospects. Organizing and planning of strategies for the evaluation of new technological products to be introduced in production processes, presentation of information from customers in their own business justifying of investment return and future implementation processes. As inside sales representative I prepared quotes, answers customer inquiries, researches new product requests and writes orders, tracked leads and negotiates pricing and availability with vendors. Served as liaison between the outside sales and technical departments. Preparing reports on daily, weekly and monthly leads and sales for the local and regional management.

"Project management is an essential skill in today’s business world. Organizations are faced with increasing pressure to complete projects within shorter time frames and with smaller budgets than in the past. Professionals need a workable method to ensure that their projects are profitable and aligned with the strategic goals of their organization." - http://www.umb.edu

" Industrial design (ID) is the professional service of creating and developing concepts and specifications that optimize the function, value and appearance of products and systems for the mutual benefit of both user and manufacturer. Industrial designers develop these concepts and specifications through collection, analysis and synthesis of data guided by the special requirements of the client or manufacturer. They are trained to prepare clear and concise recommendations through drawings, models and verbal descriptions. Industrial design services are often provided within the context of cooperative working relationships with other members of a development group. Typical groups include management, marketing, engineering and manufacturing specialists. The industrial designer expresses concepts that embody all relevant design criteria determined by the group." - http://www.idsa.org