Ensures the integrity, quality, and compliance of healthcare investigations through audits, process improvements, and collaboration with investigative teams.
Combines analytical review, training, reporting, and some policy development to support organizational goals and regulatory standards.
Conduct regular audits of Special Investigation Unit (SIU) and Compliance Investigation Unit (CIU) investigative case documentation and notes to ensure compliance.
Assist in identification of trends, discrepancies, or potential areas of risk, providing actionable items to leadership.
Develop and maintain audit tools, scorecards, and tracking systems.
Collaborate with Investigative teams and leadership to address audit findings and implement remediation plans.
Monitor implementation of process changes to ensure sustained compliance and improved quality outcomes.
Provide feedback and support to investigative leadership on documentation requirements, best practices, and quality standards.
Participate in training sessions to support ongoing staff education related to compliance and investigation excellence.
Prepare audit reports and present findings to management with clear insights and recommendations.
Track performance metrics, compliance trends, and improvement initiatives to measure program effectiveness.

Bachelor's Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience required.
3+ years experience in medical claim investigation, medical claim audit, medical claim analysis, SIU functions or healthcare fraud investigation.
2+ years with a relevant certification (CFE, AHFI, CIA, CHC, CPC or CPMA) required.

Investigation Quality Audit Analyst

Key skills