Special Investigator

Medica•Minnetonka, MN

1d•Hybrid

About The Position

The Special Investigation Unit (SIU) Investigator III conducts complex investigations into suspected fraud, waste, and abuse involving members, providers, and employees. The role leads in-depth case reviews, performs onsite audits, and evaluates evidence to support regulatory and legal requirements. It works closely with legal teams, law enforcement, and regulatory agencies to advance investigations and ensure timely responses to information requests. This position applies professional expertise with minimal supervision and serves as a resource to others in the Special Investigations Unit.

Requirements

Bachelor's degree in criminal justice, criminology, healthcare administration or related area of study or equivalent experience in a related field
5+ years of work experience in fact-finding, criminal or fraud detection, investigation and research, interviewing and field investigation and/or claims investigation in a non-health care or health care setting

Nice To Haves

Previous formal training or field experience in law enforcement at the state or federal level, criminal case management or criminal investigation.
Demonstrated ability to investigate complex issues in ambiguous environments, using critical thinking and sound judgment when information is incomplete or conflicting.
Strong investigative mindset characterized by intellectual curiosity, persistence, and a drive to uncover root causes rather than simply validate findings.
Proven ability to identifying fraud trends, patterns, and anomalies through data analysis, including the use of analytical tools and dashboards (e.g., Snowflake).
Experience developing and executing investigative strategies, including determining what evidence is needed to substantiate allegations and advance a case.
Healthcare fraud investigation experience involving government-sponsored healthcare programs, or provider fraud allegations.

Responsibilities

Conduct Complex Fraud, Waste, & Abuse Investigations: Gather, evaluate, and document evidence related to suspected fraudulent or abusive activity. Perform interviews and assessments to determine the validity and extent of concerns. Analyze claims, medical records, and other data sources to identify patterns or anomalies. Prepare detailed investigative summaries that support findings and recommended actions.
Perform Onsite Audits & Provider Reviews: Coordinate and conduct onsite inspections in alignment with investigative protocols. Review documentation, billing practices, and operational processes for compliance. Communicate findings and required corrective actions to applicable stakeholders. Maintain accurate records to support audit conclusions and follow-up activities.
Collaborate with Legal, Regulatory, & Law Enforcement Partners: Consult with internal legal counsel regarding case strategy and compliance considerations. Respond to formal information requests from regulatory agencies and law enforcement. Share relevant findings to support external investigations or regulatory reviews. Represent Medica professionally in external meetings or collaborative investigative efforts.
Support SIU Processes, Documentation, & Compliance Requirements: Maintain thorough, organized investigative files in accordance with regulatory standards. Ensure investigative activities follow internal procedures and applicable laws. Track case progress and escalate issues that may impact timeliness or outcomes. Contribute to required reporting and compliance activities for SIU operations.
Provide Expertise & Guidance to Colleagues & Stakeholders: Serve as a resource on investigative methods, fraud indicators, and regulatory expectations. Share insights and trends that strengthen fraud prevention and detection efforts. Assist team members with complex cases or procedural questions. Support training and communication efforts that promote operational integrity.
Performs other duties as assigned.