Medical Review Investigator

Position Overview

HealthPartners seeks a Medical Review Investigator to handle the intake, examination, and resolution of potential Fraud, Waste, and Abuse (FWA) claims across Medicaid, Medicare, and Commercial insurance products (both fully and self-insured). This position involves thorough evaluation of allegations through claims data analysis, medical record reviews, interviews, and site visits. Collaboration with internal teams and external stakeholders is a key aspect of the role.

Responsibilities

• Conduct investigations of suspected FWA cases, dedicating approximately 70% of efforts to these tasks.
• Carry out prepayment reviews by obtaining and analyzing medical records (10%).
• Generate comprehensive reports on investigations, including interview summaries and necessary regulatory referrals (10%).
• Assist in identifying and contributing to FWA reduction tactics such as claim system edits, dashboards for outliers, corrective action plans, and payment policies (10%).
• Maintain thorough management of investigative caseloads with timely case documentation.
• Research and apply relevant laws, policies, and regulations related to FWA investigations.
• Detect and evaluate suspicious billing trends and anomalies.
• Interview medical professionals, witnesses, and patients or members as part of investigations.
• Perform physical site inspections of providers under investigation.
• Collaborate with departments including Legal, Compliance, Contracting, Credentialing, Government Programs, and Medical Directors.
• Serve as an internal FWA subject matter expert.
• Uphold high standards of ethics and professionalism throughout all activities.

Candidate Qualifications

Minimum:

• Bachelor's degree in a relevant discipline or 4 to 7 years of investigative experience.
• Proficiency with computers, including word processing and spreadsheet software.
• Strong communication and stakeholder management capabilities.
• Ability to compose thorough and accurate written reports.
• Excellent presentation, organizational, and planning skills.
• Robust analytical skills to evaluate complex situations and develop effective solutions.

Preferred:

• Two years of experience specifically in medical FWA investigations.
• Certifications such as Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or Accredited Healthcare Fraud Investigator (AHFI) are advantageous.
• Experience utilizing data analysis to identify patterns and trends.
• Familiarity with CPT coding and relevant medical terminology.
• In-depth understanding of the evolving FWA landscape with flexibility to adapt to changes.

Company Culture and Values

HealthPartners is dedicated to fostering an inclusive environment that embraces diverse perspectives and values the contribution of every team member. The organization promotes core values including Excellence, Compassion, Partnership, and Integrity to guide behavior and decision-making.

Benefits and Inclusion

The company provides a wide range of benefits aimed at supporting employees' holistic well-being—physical, mental, emotional, and financial. HealthPartners is committed to diversity, equity, and inclusion, and offers opportunities for professional growth and work-life balance. They are also an equal opportunity employer, ensuring fair treatment regardless of protected characteristics.