A hospital care investigator is a professional who determines the eligibility of applicants for medical assistance programs and the ability of a patient or his immediate family to pay health care bills, handles insurance information from source departments and prevents health care fraud. To become a hospital care investigator, you need to pursue a bachelor’s degree, preferably in a medical or nursing field and fulfill state-specific licensing requirements.

Determining Eligibility

Individuals who want to apply for medical assistance may need to meet specific federal and state eligibility requirements. A hospital care investigator interviews applicants to verify issues such as identity, age, family size and income. For instance, if a person with a disability is looking to apply for Medicaid, a hospital investigator may vet their identification documents to verify age, residency and citizenship. He also may analyze applicants’ financial information, including wages, Social Security, interest and pension.

Assisting Applicants

A hospital care investigator helps patients make successful applications for medical assistance programs. He uses his experience to advice applicants on the pros and cons various health care plans and may help them choose among providers. At times, a hospital investigator may translate documents to a language an applicant easily understands. For example, when a person with a communication disorder wants to apply for a medical assistance program, the hospital investigator may find a speech specialist to facilitate effective communication.

Managing Payments

As a hospital care investigator, it’s your job to manage payments from third-party payers. This typically involves presenting medical assistance providers with invoices to ensure reimbursed funds are consistent with the facility’s records. You also may furnish third-party payers with the hospital’s bank accounts for payment purposes. If a patient has a health care insurance plan with unclear terms, you can initiate communication with the providers to clarify the issue. This helps protect hospitals from financial losses.

Curbing Fraud

Fraud involves intentional misrepresentation of information or deception. Although it is the work of internal auditors to detect and prevent fraud, hospital care investigators can play a key role given that they spend more time perusing through a wide variety of documents. If you suspect that a medical assistance applicant’s financial documents are not genuine, for example, you can inform a relevant department to verify the information. An effective hospital care investigator has excellent analytical skills and is detail-oriented.