Become a Medical Fraud Investigator: Education & Career Roadmap

Find out how to become a medical fraud investigator. Research the education requirements and learn about the experience you need to advance your career in claims investigations.

Do I Want to Be a Medical Fraud Investigator?

Medical fraud investigators, sometimes known as insurance investigators, review and analyze suspicious medical claims filed by patients, providers and insurance carriers. They conduct investigations by looking at medical records, interviewing medical personnel and communicating with insurance claims adjusters. Medical fraud investigators also might identify fraudulent claims, gather evidence and report findings to regulatory authorities. Long hours are often worked by these investigators, and weekend work is to be expected.

Job Requirements

According to the U.S. Bureau of Labor Statistics (BLS), the minimum education requirement for insurance investigators is the equivalent of a high school diploma. However, job postings for medical fraud investigators listed in August 2012 on indicated that most employers wanted applicants who held a bachelor's degree. Relevant experience is usually required as well. The following table highlights common career requirements for medical fraud investigators:

Common Requirements
Degree Level Bachelor's degree**
Degree Field Law enforcement, criminal justice or health care**
Licensure Insurance investigators are required to obtain licensure in some states*
Experience 2-5 years' experience in law enforcement investigations, claims submissions and/or medical investigations**
Key Skills Comfortable collaborating with internal departments and external agencies, able to work without supervision, strong eye for detail, able to conduct interviews, good decision making skills, able to negotiate, capable of working as a team player**
Computer Skills Able to create spreadsheets and reports, comfortable with claims investigations software** and familiar with electronic health records*
Technical Skills Knowledge of medical terminology, pharmacology and pathology; familiar with the health care claims billing and payment process**
Additional Requirements Be willing to work around the clock and on weekends, as needed*

Sources: *U.S. Bureau of Labor Statistics (BLS), ** August 2012 job postings

Step 1: Earn a Bachelor's Degree

The August 2012 job postings for medical fraud investigators indicated that some employers preferred applicants with a bachelor's degree related to criminal justice or health care. The BLS also confirmed that employers often hire investigators with a background in law enforcement since these individuals tend to have more experience with claims investigations.

Bachelor's degree programs related to health care administration teach students about health facilities operations, budgeting, medical billing and health care records. Criminal justice bachelor's degree programs discuss policing strategies, investigative techniques, judicial process, crime prevention and crisis management.

Success Tip:

  • Major in one field, minor in the other. Medical fraud investigators often need skills training from both of the above listed fields. Thus, students might choose to major in health care administration and minor in criminal justice or vice versa.

Step 2: Gain the Necessary Work Experience

According to the job postings, the majority of employers were looking for medical fraud investigators with 2-5 years of experience, particularly in the areas of insurance billing, medical chart coding or claims investigations. Alternatively, candidates could have extensive experience running investigations or working in law enforcement.

Step 3: Become Licensed as a Medical Fraud Investigator

Some states require investigators to obtain a license. The licensing process varies by state, but generally includes meeting educational requirements and passing a licensing exam. In most states, license renewal requires that professionals pay a fee and complete continuing education (CE) coursework. Potential CE courses related to this career might cover topics in health care law, insurance billing, medical terminology or new medical procedures.

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