Medical Review Associate Investigator

About the role

The Medical Review Associate Investigator is part of the Special Investigations Unit (SIU) team and supports the identification, assessment, and preliminary analysis of potential Fraud, Waste, and Abuse (FWA) concerns across Medicaid, Medicare, and Commercial (fully insured and self-funded) lines of business.

Responsibilities

• Assists with full lifecycle Fraud, Waste, and Abuse (FWA) investigations by performing preliminary fact finding, issue identification, and analytical review under the guidance of an SIU Investigator.
• Reviews and analyzes claims data, billing patterns, and available medical documentation to identify inconsistencies, risk indicators, and potential FWA schemes.
• Applies investigative criteria, policies, and professional judgment to evaluate allegations, assess case complexity, and support case prioritization.
• Identifies documentation gaps, develops investigative observations, and recommends next steps to advance investigative review.
• Documents analytical findings, summaries, and risk considerations in the case management system to support investigator determinations.
• Supports prepayment and concurrent review activities through analysis of claims and records prior to payment.
• Supports identifying trends, anomalies, or emerging patterns indicative of potential FWA across providers, services, or claim types.
• Summarizes findings and escalates identified risks to SIU Investigators or leaders for further investigation or intervention.
• Prepares investigative summaries, timelines, and documentation analyses that contribute to formal investigative reporting and regulatory decision making.
• Reviews records for accuracy, relevance, and consistency with investigative hypotheses, flagging discrepancies or concerns.
• Supports coordination related to regulatory or oversight notifications (e.g., DHS, OIG) by interpreting requirements, assessing investigative impact, and ensuring appropriate internal routing, without independently issuing determinations or referrals.
• Participates in structured training and applied learning related to investigative techniques, medical record review, claims analysis, and FWA typologies.
• Identifies recurring investigative challenges, documentation issues, or workflow inefficiencies and recommends process or control improvements.
• Contributes to operational tracking and internal reporting through analytical review and quality validation, supporting informed decision making by SIU leadership.

Requirements

Education, Experience or Equivalent Combination: Associate degree in healthcare administration, business, criminal justice, or related field OR equivalent relevant work experience. 2–3 years of experience in healthcare investigations, medical review, audits/compliance, or payment integrity, or related work requiring strong attention to detail.

Knowledge, Skills, and Abilities: Proficient in using personal computers, word processing, and spreadsheets. Strong communication and stakeholder management skills. Proficient in drafting detailed and accurate written reports. Excellent presentation, planning and organizational skills. Strong analytical skills with the ability to assess complex situations and identify effective solutions.

Preferred Qualifications

• 2 years’ experience in medical fraud, waste, and abuse (FWA) investigations.
• Professional certification as a Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AHFI), or similar.
• Understanding of the current FWA landscape and trends with the ability to adapt to shifting priorities and evolving requirements.
• Demonstrated familiarity with CPT codes and terminology.
• Experienced in using data analysis to uncover trends and patterns.

Skills

• Proficient in using personal computers, word processing, and spreadsheets.
• Strong communication and stakeholder management skills.
• Proficient in drafting detailed and accurate written reports.
• Excellent presentation, planning and organizational skills.
• Strong analytical skills with the ability to assess complex situations and identify effective solutions.

Benefits

Designed To Support Your Total Health As a HealthPartners colleague, we’re committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities.

Pay

N/A

Schedule

N/A