Clinical Investigator – CPC Certified
Location: Noida, Uttar Pradesh, India
Company: Optum (UnitedHealth Group)
Job Category: Claims
Job Type: Full-Time
Requisition Number: 2330678
Position Overview
Optum is hiring a Clinical Investigator – CPC Certified to support claim investigation, fraud waste and abuse (FWA) detection, coding-based claim review, and medical policy compliance. The role involves analyzing pre-payment claims using CPT/ICD coding expertise, reviewing medical records, and ensuring accurate claim adjudication in alignment with clinical and reimbursement guidelines.
This position is ideal for healthcare professionals with coding certification (CPC) and experience in claims, clinical review, or US healthcare operations.
Key Responsibilities
Prevent payment of inaccurate, abusive, or potentially fraudulent claims using clinical knowledge, CPT/ICD coding, CMC guidelines, and client-specific policies.
Review pre-pay claims with medical records to assess payment correctness and clinical justification.
Interpret CPT guidelines, reimbursement rules, contracts, and medical policies during claim evaluation.
Participate in client regulatory meetings and support discussions related to clinical reviews.
Interact with providers, advocates, and legal teams to support resolution and minimize provider friction.
Work on special projects, data analysis, and cross-functional collaboration as required.
Monitor claim inventory to ensure performance guarantee adherence.
Ensure compliance with federal and state guidelines, company policies, and audit requirements.
Perform work independently and act as a resource for peers when needed.
May coordinate activities of team members based on project requirements.
Required Qualifications
Educational Background (Any one):
BHMS / BAMS / BUMS
BPT / MPT
B.Pharm / M.Pharm
B.Sc Nursing
BDS (with minimum 1 year corporate experience)
Certifications & Skills:
Certified Professional Coder (CPC) – AAPC
CPT & ICD coding experience
OR must pass CPC certification (if not yet certified)
Minimum 6 months experience as a certified coder
Strong analytical, comprehension, and documentation skills
High attention to detail and quality-focused mindset
Extensive work experience within the healthcare/claims function preferred
Preferred Qualifications
Claims processing experience
Familiarity with US healthcare and managed care systems
Experience with medical records and documentation review
Knowledge of health insurance operations and coding workflows
About Optum / UnitedHealth Group
Optum, part of UnitedHealth Group, is a global healthcare technology and services leader. The organization focuses on improving healthcare outcomes, promoting equity, and advancing the healthcare system through data-driven insights. Employees benefit from an inclusive culture, development opportunities, and impactful work that supports healthier communities worldwide.
Job Details
Business Segment: Optum
Employee Status: Regular
Schedule: Full-Time
Shift: Day Shift
Travel: No
Overtime Status: Exempt
Telecommute: No
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