Investigator, Medical Review Associate

Investigator, Medical Review Associate HealthPartners/GHI - 3.7 Bloomington, MN Job Details Full-time $29.57 - $44.35 an hour 1 day ago Benefits Health insurance Qualifications Medical claims Document review (document control) Report writing Medicare Word processing Triage Healthcare Administration Regulatory compliance Healthcare fraud investigations Certified Fraud Examiner Process improvement Mid-level Criminal Justice Pattern recognition Certified Professional Coder Analysis skills Associate's degree in criminal justice Decision making Data analytics CPT coding Organizational skills Insurance investigations Investigative reports Business Administration Productivity software Regulatory audits Business Associate's degree Escalation handling 2 years Documentation review Communication skills Technical Proficiency Stakeholder relationship building Stakeholder management Full Job Description

JOB DESCRIPTION

HealthPartners is hiring a Medical Review Investigator Associate. This role 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.

Licensure/ Registration/ Certification:

N/A 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

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. 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. 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. 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.

ABOUT US

At HealthPartners we believe in the power of good - good deeds and good people working together. As part of our team, you'll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work. We're a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world. At HealthPartners, everyone is welcome, included and valued. We're working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change. 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. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care. Join us in our mission to improve the health and well-being of our patients, members, and communities. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.

JOB INFO

Job Identification 119447 Organization HealthPartners/GHI, HealthPartners Enterprise Posting Date 04/24/2026, 01:01 PM Locations 8170 33rd Ave S - Bloomington Work Schedule M-F, business hours Hours Per Week/FTE 40 hrs weekly / 1.0 FTE Job Shift Day Position Type Full-time regular Job Category Claims Department Payment Integrity Pay Range $29.57 - $44.35 hourly Pay Range Statement Compensation is based on the level and requirements of the role. Pay within our ranges may also be determined by education, experience, knowledge, skills, location, and abilities as well as internal equity. Hired candidates may be eligible to receive additional compensation based on role (e.g., shift differential, bonus, sales incentive, productivity pay, etc.). Overtime Eligibility Status Exempt Worker Type Employee