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.

Should I Become 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.

Career Requirements

Degree Level Bachelor's degree
Degree Field Law enforcement, criminal justice or health care
Licensure/Certification Some states require licensure; voluntary certification may improve job prospects
Key Skills Attention to detail; interviewing skills; negotiation skills; mathematical and analytical skills; knowledge of medical terminology, pharmacology and pathology; familiar with the health care claims billing and payment process; comfortable collaborating with internal departments and external agencies
Salary (2014) $62,220 (median for claims adjusters, examiners, and investigators)

Sources: U.S. Bureau of Labor Statistics (BLS), August 2015 job postings

Step 1: Earn a Bachelor's Degree

Some employers prefer to hire medical fraud investigators who have completed 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

The majority of employers look for medical fraud investigators with 2-5 years of experience, particularly in the areas of insurance billing, medical chart coding or claims investigations. This experience is usually gained in entry-level positions working alongside experienced investigators. As new investigators gain experience in the field, they are assigned more complex cases and are able to work more independently. Alternatively, candidates may need 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.

Step 4: Seek Certifications

Certifications such as Certified Insurance Fraud Investigator (CIFI) or Certified Fraud Examiner (CFE) credentials may improve a medical fraud investigator's job prospects. The CFE credential, offered by the Association of Certified Fraud Examiners (ACFE), requires that a candidate become an associate member of the ACFE, submit a detailed work history and three professional recommendations and pass a CFE exam. To qualify to take the CIFI exam, administered by the International Association of Special Investigation Units, a candidate must have a minimum of a bachelor's degree and experience in either insurance investigation or law enforcement.

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