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:

• (70%) - Investigate allegations of potential FWA.
• (10%) - Perform prepayment activities, including obtaining and analyzing records.
• (10%) - Prepare detailed investigation reports, interview summaries, and regulatory referrals.
• (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.

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.