Clinical Investigator – CPC Certified
Location: Noida, Uttar Pradesh, India
Job Type: Full-Time | Day Shift
Business Segment: Optum
Position Overview
Optum, a global leader in healthcare services and technology, is seeking a certified Clinical Investigator to support claims investigation, fraud prevention, and clinical review processes. The role focuses on analyzing medical claims, reviewing medical records, identifying inappropriate billing patterns, and ensuring compliance with state, federal, and organizational guidelines.
This position plays a critical part in improving health outcomes by supporting accurate claims processing for health plans, commercial clients, and government programs.
Key Responsibilities
Review and prevent payment of potentially fraudulent, abusive, or non-compliant medical claims using clinical expertise, CPT/ICD coding knowledge, CMC guidelines, and client-specific policies.
Evaluate prepay claims and corresponding medical records to ensure payment accuracy and compliance.
Apply CPT guidelines, reimbursement policies, contracts, and applicable clinical review standards.
Participate in meetings with regulatory teams, client representatives, legal partners, and healthcare providers.
Assist with investigative processes, provider abrasion cases, and special business or client-driven projects.
Analyze data and collaborate with internal and external stakeholders to resolve claims-related issues.
Monitor claim inventory regularly to meet performance metrics and service guarantees.
Support prospective teams with reporting and special operational assignments.
Work independently while also serving as a resource for team members and coordinating activities when required.
Maintain full compliance with employment contracts, organizational policies, work-shift adjustments, and operational requirements in a dynamic business environment.
Required Qualifications
Medical degree: BHMS, BAMS, BUMS, BPT, MPT.
B.Pharm or M.Pharm candidates are eligible.
Certified Professional Coder (CPC) – mandatory.
Experience with CPT and ICD coding or willingness to pass AAPC CPC certification.
Minimum 6 months of experience as a certified coder.
B.Sc. Nursing or BDS with at least 1 year of corporate experience.
Strong attention to detail, analytical ability, and comprehension skills.
Extensive work experience within the healthcare or clinical review function.
Preferred Qualifications
Experience in claims processing or health insurance.
Knowledge of managed care, US healthcare operations, and medical coding standards.
Familiarity with reviewing medical records and clinical documentation.
Company Overview
UnitedHealth Group’s mission is to help people live healthier lives and to make the health system work better for all. The organization is committed to delivering equitable, high-quality care, reducing health disparities, and fostering a diverse and inclusive environment.
Additional Information
Requisition Number: 2330678
Employee Status: Regular
Travel: No
Overtime Status: Exempt
Telecommuter Position: No
Schedule: Full-time, Day Job
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