Medical Review Investigator

HealthPartners is hiring a Medical Review Investigator. The Medical Review Investigator is responsible for the intake, investigation, and resolution of potential Fraud, Waste, and Abuse (FWA) allegations involving Medicaid, Medicare, and Commercial (fully and self-insured) product lines. Primary responsibilities include evaluating allegations, analyzing claims data, reviewing medical records, conducting interviews, and performing investigative site visits. This role requires frequent collaboration with both internal departments and external stakeholders.

MINIMUM QUALIFICATIONS: 

• Education, Experience or Equivalent Combination:
• Bachelor’s degree in relevant field, or 4-7 years of Investigative Experience 
• 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:
  • Experienced in using data analysis to uncover trends and patterns.
• 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. 

ESSENTIAL DUTIES:  

1. (70%) - Investigate allegations of potential FWA. 
2. (10%) – Perform prepayment activities, including obtaining and analyzing records. 
3. (10%) – Prepare detailed investigation reports, interview summaries, and regulatory referrals. 
4. (10%) – Identify opportunities for, and contribute to, FWA mitigation strategies including claim system edits, outlier dashboards, corrective action plans, and reimbursement policies.

*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.