Clinical Investigator
Company: Optum (UnitedHealth Group)
Location: Chennai, Tamil Nadu, India
Job Category: Claims
Requisition Number: 2371605
Employment Type: Full-Time
Overtime Status: Exempt
Travel Requirement: No Travel
Posted On: 18 June 2026
Job Summary
The Clinical Investigator is responsible for investigating, recovering, and resolving healthcare claims while identifying potentially fraudulent or abusive claims. The role involves utilizing medical expertise, coding knowledge, and healthcare guidelines to ensure claim accuracy, compliance, and cost containment.
Key Responsibilities
Claims Investigation & Review
Investigate and resolve healthcare claims, recoveries, and payment discrepancies.
Prevent payment of potentially fraudulent, abusive, or inaccurate claims.
Review claims using medical expertise, CPT/Diagnosis coding knowledge, CMC guidelines, client-specific guidelines, and member policies.
Conduct detailed claim analysis to ensure appropriate reimbursement.
Compliance & Quality Management
Ensure adherence to state and federal healthcare regulations.
Maintain compliance with reimbursement policies, client contracts, and company procedures.
Follow quality standards and documentation requirements.
Operational Support
Assist prospective teams with reporting and special projects.
Work independently with minimal supervision.
Serve as a resource for team members when required.
Coordinate activities and support operational objectives.
Medical Record & Case Review
Review medical records and clinical documentation.
Support investigations involving complex or high-value claims.
Monitor and evaluate claims for accuracy and compliance.
Required Qualifications
Educational Qualification
Any Graduate (Mandatory).
Preferred: BHMS, BAMS, BUMS, BPT, or MPT.
B.Sc. Nursing or BDS candidates must have at least 1 year of corporate experience.
Certifications
Certified through AAPC.
CPC (Certified Professional Coder) certification is mandatory.
Experience
Medical Graduates: Relevant healthcare or coding experience preferred.
Non-Medical Graduates: Minimum 1 year of specialty coding experience (E&M, Surgery, Anesthesia, etc.).
Experience solely in HCC coding is not sufficient.
Skills Required
Strong knowledge of CPT, ICD, and medical coding principles.
Excellent analytical and problem-solving skills.
Strong attention to detail and quality orientation.
Good comprehension and investigation skills.
Ability to work independently and manage priorities effectively.
Preferred Qualifications
Claims processing experience.
Health insurance and managed care experience.
Knowledge of US Healthcare systems and medical coding.
Familiarity with medical records and clinical documentation review.
Key Contribution
Protect organizational resources by identifying fraudulent or abusive claims.
Improve claim accuracy and compliance.
Support healthcare cost management and quality assurance initiatives.
Salary Criteria
Expected Salary: ₹4.5–8.0 LPA for CPC-certified candidates with 1–3 years of medical coding, claims investigation, or US healthcare experience, depending on qualifications and domain expertise.
Uttar Pradesh :
Agra | Gajraula | Gautam buddha Nagar | Ghaziabad | Gorakhpur | Greater Noida | Jhansi | kanpur | Lucknow | Mathura | Noida | Park City | Prayagraj | Satyamev | Varanasi |Gujarat :
Ahmedabad | Ankleshwar | Baroda | Bharuch | Gandhinagar | Gujarat | Halol | Jhagadia | Mehsana | surat | Tarasadi | Vadodara | Vapi |Maharashtra :
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Japan | Saitama |Tokyo :
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