Summary
Overview
Work History
Education
Skills
Certification
Languages
Timeline
Education and Training
Generic

Stacy Griffin

Plainfield

Summary

Results-driven Senior Investigator with over 10 years of expertise in managing high-volume caseloads within the healthcare sector, consistently achieving exceptional outcomes. In-depth knowledge of Medicare and Medicaid policies, complemented by strong contract management skills. Recognized as a strategic thinker and resourceful leader with a solid track record of success in complex investigations. Committed to excellence with meticulous attention to detail and a persuasive communication style, effectively training junior investigators to thrive in fast-paced, high-pressure environments.

Overview

16
16
years of professional experience
1
1
Certification

Work History

SIU Senior Investigator

CVS HEALTH CORPORATION
11.2018 - Current
  • Conducts more high level, complex investigations of known or suspected acts of healthcare fraud and abuse.
  • Routinely handles cases that are sensitive or high profile, those that are national in scope, complex cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes
  • Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc
  • Researches and prepares cases for clinical and legal review
  • Documents all appropriate case activity in case tracking system
  • Makes referrals, both internal and external, in the required timeframe
  • Facilitates the recovery of company and customer money lost as a result of fraud matters
  • Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators.
  • Assists Investigators in identifying resources and best course of action on investigations
  • Serves as back up to the Team Leader as necessary.
  • Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
  • Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
  • Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
  • Provides input regarding controls for monitoring fraud related issues within the business units.
  • Planned and managed Onsite/Audit operations
  • Maintained organized records of all information and material pertinent to open investigations.

Program Integrity Analyst II- Medicare

AdvanceMed- NCI
05.2015 - 11.2018
  • Conduct independent investigations resulting from discovery of situations that potentially involve fraud, waste, or abuse
  • Utilize data analysis techniques to detect aberrancies in Medicare claims data and proactively seek non compliance providers and develops leads received from a variety of sources (e.g., AUSA, CMS, FBI, OIG, fraud alerts)
  • Draft written referrals to law enforcement and take steps to initiate recoupment o overpaid monies.
  • Respond to requests for information from law enforcement and maintain cases that were referred to law enforcement.
  • Review information contained in standard claim processing system files(e.g., claims history, provider files to provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare polices and initiates appropriate action.
  • Develop and prepare potential Fraud Alerts and Program Vulnerabilities for submission to CMS
  • Pursue applicable administrative actions during investigations/ case development (e.g., payment suspensions, civil monetary penalties, requests for exclusions, etc.).
  • Conduct onsite audits in conjunction with investigation development.
  • Provide support of cases at hearing/appeal and AU level.
  • Maintain chain of custody on all documents as it pertains to confidentiality and security guidelines.

Healthcare Fraud Investigator II

Cahaba Safeguard Administrators
10.2013 - 05.2015
  • Independently identify, review, analyze and develop allegations of fraud and abuse against Medicare and/or Medicaid funds in accordance with the regulatory guidelines set forth by CMS.
  • Maintain a complete record of all investigative steps and all related documentation in a Case Management System.
  • Initiate and record administrative actions taken in Centers for Medicare and Medicaid Services National Fraud Data Base.
  • Plan and prepare and conduct onsite-visits and audits at provider place of business.
  • Perform and interpret data analysis of provider's claims and financial records.
  • Interview beneficiaries, complainants, and providers.
  • Provide administrative support to Law Enforcement, and provide assistance up to and including testimony in court for DOJ cases.
  • Coordinate with Medicare Administrative Contractors and Heat Teams (DOJ, AUSA, and OIG) in high-risk fraud areas to combat fraud and abuse.
  • Request and Review findings from Medical Review of medical records.
  • Research and secure documentation needed for all external request for information from law enforcement and external entities.
  • Prepare cases for referral to external governmental agencies and law enforcement agencies.
  • Complete a summary of findings with detail rationale prior to closing investigations.
  • Mentor and Train investigators on the life cycle of an investigation from initiation to successful closing the investigation or case.
  • Conduct independent cost reports and financial audits resulting from the discovery of situations that potentially involve fraud and abuse.

Customer Service Advocate

Blue Cross Blue Shield
09.2009 - 10.2013
  • Quote medical benefits/ accumulation of deductible and allowance of policy to Members/ Providers, Producer/ Agents.
  • Processed member Initial/ Reinstatement applications.
  • Research Predetermination of Benefits /Pre-Certification request.
  • Perform Deductible Downgrade/ Upgrade Rate Quotes for Individual Market and Medicare Supplement plans
  • Provide a full range of claim support services to ensure proper disbursement of payments for Medicare Supplement, Individual Markets.
  • Identified and investigated allegations of aberrancies in provider billing and allegations of abuse.
  • Reconcile accounting errors to protect brand -alleviate cost to Members and Providers.
  • Finalized transfer and conversion applications.
  • Encouraged customers to become self-sufficient with web-based and mobile support tools.
  • Stayed on top of changing internal policies, company offerings and promotions to effectively serve every customer.
  • Mentored new employees on procedures and policies to maximize team performance.
  • Maximized customer satisfaction by handling customer email and telephone interactions.
  • Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
  • Completed continuing education and training programs for professional development.

Education

Some College (No Degree) -

CVS Percipo

Some College (No Degree) - Medical Insurance Coding

Integrity Coding

Bachelor of Science - Information Technology

Directions Training Center
08.2015

Bachelor of Science - Criminal Justice

Loyola University of Chicago
Chicago, IL
04.2004

Skills

  • Data-driven trend evaluations
  • Fraud investigation in healthcare
  • Data organization
  • Project oversight
  • Healthcare vocabulary expertise
  • Research analysis

    • Experienced with data analysis software: SQL, Python, Excel, data visualization (eg, Tableau, Power BI), machine learning, and statistical analysis

Certification

Microsoft Office Specialist Certification Program

Directions Training Center - Oak Brook, IL

Languages

English
Native or Bilingual

Timeline

SIU Senior Investigator

CVS HEALTH CORPORATION
11.2018 - Current

Program Integrity Analyst II- Medicare

AdvanceMed- NCI
05.2015 - 11.2018

Healthcare Fraud Investigator II

Cahaba Safeguard Administrators
10.2013 - 05.2015

Customer Service Advocate

Blue Cross Blue Shield
09.2009 - 10.2013

Some College (No Degree) - Medical Insurance Coding

Integrity Coding

Bachelor of Science - Information Technology

Directions Training Center

Bachelor of Science - Criminal Justice

Loyola University of Chicago

Some College (No Degree) -

CVS Percipo

Education and Training

Data Analysis in Healthcare, August 2025   ELVTR

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