Medical Review Associate Investigator

HealthPartners is hiring a Medical Review Associate Investigator. 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. This role applies analytical judgement and discretion to evaluate allegations, triage incoming referrals, assess risk indicators, and support investigative decision making under the guidance of senior SIU staff.

Primary responsibilities include performing structured intake analysis, conducting preliminary review of claims and provider data, assessing documentation and medical record completeness, identifying investigative risks or trends, and supporting prioritization of cases based on defined FWA indicators. 

This position is a professional, developmental role designed to build investigative competencies and provide exposure to investigative workflows, medical record handling, claims documentation practices, and regulatory process tracking. Successful performance may support progression into SIU investigative roles, subject to business need, demonstrated competencies, and meeting minimum qualifications for the Investigator position. 

MINIMUM QUALIFICATIONS: 

• 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: 

• Education, Experience or Equivalent Combination:

  • 2 years’ experience in medical fraud, waste, and abuse (FWA) investigations.

• Licensure/ Registration/ Certification:

  • Professional certification as a Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AHFI), or similar.  

• Knowledge, Skills, and Abilities:

  • 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.

ESSENTIAL DUTIES:  

1. 60% – Investigative Analysis, Case Support & Risk Assessment

• 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.

2. 15% – Prepayment, Monitoring & Pattern Detection Support

• Supports prepayment and concurrent review activities through analysis of claims and records prior to payment.

• Assists with 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.

3. 15% – Investigative Documentation, Reporting & Regulatory Coordination

   • 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.

4. 10% – Investigative Development, Operational Insight & Continuous Improvement

• 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.

*Job description rankings/percentages are intended to reflect normal averages over an extended period of time, and are subject to daily variances.  Quality and efficiency standards should at no time be compromised to meet the average expectations expressed above.  Job descriptions are subject to change to accommodate organization or department needs.

ORGANIZATIONAL EXPECTATIONS:

Values

All colleagues are expected to live our values:  

Excellence: We strive for the best results and always look for ways to improve.

Compassion: We care and show empathy and respect for each person.

Partnership: We are strongest when we work together and with those we serve.

Integrity: We are open and honest, and we keep our commitments.

Additional Expectations:

• Manage an investigative caseload, including timely documentation and reporting of case activities.

• Research and apply internal and external policies, procedures, laws, and/or regulations. 

• Identify and analyze suspicious billing patterns, trends, and anomalies. 

• Interview professionals, witnesses, and patients/members. 

• Perform investigative provider site visits. 

• Collaborate with internal partners including Legal, Compliance, Contracting, Credentialing, Government Programs, and the Health Plan Medical Directors

• Serve as an internal resource and subject matter expert on FWA.

• Demonstrate high standards of integrity and professionalism.