Special Investigator

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. 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. Key Accountabilities: 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. Required Qualifications: 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 Preferred Qualifications: 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. This position is an Office role, which requires an employee to work onsite at our Minnetonka, MN office, on average, 3 days per week. The full salary grade for this position is $62,700 - $107,500. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $62,700 - $94,080. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law. Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic. Qualifications Skills Behaviors : Motivations : Education Experience Licenses & Certifications Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Medica