Clinical Investigator
Company: Optum (UnitedHealth Group)
Location: Hyderabad, Telangana, India
Department: Claims Investigation / Healthcare Operations
Job Type: Full-Time
Requisition Number: 2347870
Experience Required: 0–2 Years in Healthcare Claims Review, Clinical Operations, Medical Coding, or Insurance Operations
Education: Medical Degree such as BHMS, BAMS, BUMS, BPT, MPT, B.Sc Nursing, or BDS
About Optum
Optum, part of UnitedHealth Group, is a global healthcare organization dedicated to improving health outcomes through technology-enabled healthcare services, advanced analytics, and clinical expertise. The organization supports healthcare systems worldwide by connecting patients, providers, and healthcare data to deliver efficient, patient-centered care.
With a strong presence across healthcare operations, clinical services, and analytics, Optum helps healthcare organizations optimize clinical workflows, improve healthcare access, and strengthen healthcare integrity.
Job Overview
Optum is seeking a Clinical Investigator to support healthcare claims investigation and fraud prevention initiatives within the Claims Operations team. This role involves reviewing complex and high-value medical claims to identify potential instances of fraud, waste, and abuse (FWA).
The Clinical Investigator will analyze medical records and billing information to detect discrepancies such as upcoding, unbundling, duplicate billing, or misrepresentation of medical services. The position requires strong clinical knowledge, familiarity with medical coding systems, and an understanding of healthcare policies to ensure accurate claim adjudication and compliance with regulatory guidelines.
Key Responsibilities
Healthcare Claims Investigation
Review medical records and claim submissions to identify discrepancies between billed services and clinical documentation.
Investigate complex and high-value claims to detect potential fraud, waste, or abuse.
Analyze billing practices to identify patterns such as upcoding, unbundling, duplication, or misrepresentation of medical services.
Fraud, Waste, and Abuse Prevention
Prevent the payment of potentially fraudulent or abusive claims using clinical expertise and coding knowledge.
Apply CPT codes, diagnosis codes, and CMS guidelines while reviewing claims for accuracy and compliance.
Follow client-specific guidelines and member policies during claim investigations.
Compliance and Regulatory Adherence
Ensure compliance with federal and state healthcare regulations as well as payer contractual requirements.
Support adherence to internal healthcare compliance standards and claims review protocols.
Maintain accurate documentation of investigation findings and claim review outcomes.
Data Analysis and Reporting
Identify provider behavior patterns that may indicate aberrant billing practices.
Support reporting and analytics initiatives related to claims investigations and healthcare integrity.
Assist internal teams with special projects related to claims review and fraud detection.
Team Collaboration and Communication
Coordinate with team members to share investigation findings and process updates.
Collaborate with cross-functional teams to improve claims review processes and fraud prevention strategies.
Contribute to knowledge sharing within the claims investigation team.
Required Skills and Competencies
Strong analytical and investigative skills in reviewing healthcare claims and medical documentation.
Knowledge of medical coding systems including CPT and diagnosis codes.
Ability to identify irregular billing patterns and potential healthcare fraud.
Strong attention to detail and accuracy in clinical documentation review.
Effective communication and collaboration skills.
Ability to work independently and manage multiple investigations simultaneously.
Professional Requirements
Medical qualification such as BHMS, BAMS, BUMS, BPT, MPT, B.Sc Nursing, or BDS.
Candidates with at least 6 months of relevant healthcare or corporate experience are preferred, though fresh graduates from eligible medical disciplines may apply.
Strong attention to detail, analytical thinking, and quality-focused approach to claims review.
Preferred Qualifications
Experience in healthcare claims processing or insurance operations.
Knowledge of the US healthcare system and medical coding guidelines.
Familiarity with managed care environments and healthcare billing processes.
Experience reviewing clinical documentation and medical records.
Why Join Optum
Optum provides healthcare professionals with opportunities to work at the intersection of healthcare, technology, and analytics. Employees gain exposure to global healthcare operations while contributing to initiatives that improve healthcare transparency, prevent fraud, and ensure accurate reimbursement systems.
Job Location
Hyderabad, Telangana, India.
Uttar Pradesh :
Agra | Gajraula | Gautam buddha Nagar | Ghaziabad | Gorakhpur | Greater Noida | Jhansi | kanpur | Lucknow | Mathura | Noida | Park City | Prayagraj | Satyamev | Varanasi |Gujarat :
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Hajipur | Patna |Kerala :
Kannur | Kochi | Malappuram | Thiruvananthapuram | Trivandrum |Pondicherry (Puducherry) :
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Ranchi |Sikkim :
Rangpo |India :
Siliguri |Illinois :
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Andover | Billerica | Boston | Cambridge | Devens | Lexington | Massachusetts | Medford and Somerville | Rockland |Wisconsin :
Appleton | Kenosha | Pleasant Prairie | Portage | Waukesha |United states :
Arizona | Buffalo Grove | Clayton | Downers Grove | fairmont | Georgia | Keene | Michigan | Mt. Pleasant | New Jersy | OH | Piedmont | Salisbury | United States | Whitesboro | Winston-Salem |Georgia :
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Frank Scottile Blvd |Missouri :
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Hawai | kentucky | Sylmar | Woonsocket |Nebraska :
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Washington |Delaware :
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Mitte |Mecklenburg Vorpommern :
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Saarbrucken |Switzerland :
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Bulgaria | Vedant |Denmark :
Copenhagen | Denmark |Europe :
Europe | France | Latvia | Lendava | Leuven | Poland | Slovenia | Spain |Finland :
Finland |Istanbul :
Istanbul | Turkey |Norway :
Norway | NOrway |Romania :
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Brinny | Ringaskiddy |Carlow :
Carlow |Republic of Ireland :
Cork | Dublin | Limerick | Waterford |Ulster :
Donegal |Meath :
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Dún Laoghaire |Galway :
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China | Quarry Bay |Liaoning :
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Netherlands |Remote Australia :
Arkansas | Remote Australia |New South Wales :
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South Yarra |United Kingdom :
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Harrogate |South Yorkshire :
Sheffield |Oxfordshire :
Witney |Ontario :
Renfrew | Richmond Hill | Mississauga | North York | Uxbridge | Australia |Canada :
Canada |Quebec :
Montreal |Brussels :
Brussels |Antwerp :
Heist op den Berg |Flemish Brabant :
Zaventem |South America :
Argentina | Peru |Brazil :
Sao paulo | Brazil |Attica :
Athens | Koropi |Greece :
Greece |North Island :
Auckland |New Zealand :
New Zealand |Austria :
Austria |Vienna :
Vienna |Catalonia :
Barcelona |Madrid :
Madrid |Cebu Province :
Cebu City |Philippines :
Manila |Croatia :
Croatia |Zagreb :
Zagreb |Estonia :
Tartu | Estonia |Harju County (Maakond) :
Tallinn |Hà Nội :
Hà Nội | Hanoi |Ho Chi Minh :
Ho Chi Minh City |Italy :
Italy |Lombardy :
Rho |Jakarta :
Jakarta |East Java :
Surabaya |Japan :
Saitama | Japan |Tokyo :
Otemachi |North Ostrobothnia :
Oulu |Southwest Finland (Varsinais-Suomi) :
Turku |Remote Korea :
Remote Korea |Republic of Korea :
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