Senior Clinical Investigator – CPC Certified
Location: Hyderabad, Telangana, India
Job Category: Medical & Clinical Operations
Requisition Number: 2327427
Employment Type: Full-Time | Day Shift
Role Overview
Optum, a global healthcare and technology organization, is hiring a Senior Clinical Investigator to support medical claim investigations, fraud prevention, clinical review accuracy, and compliance activities. This position is vital in ensuring accurate claim adjudication, identifying inappropriate billing patterns, and safeguarding healthcare system integrity.
The role directly contributes to improved patient outcomes by ensuring claims are processed with clinical accuracy and regulatory compliance. Candidates will work in a collaborative, data-driven, and highly regulated environment supporting both domestic and international stakeholders.
Key Responsibilities
Identify and prevent payment of fraudulent or abusive claims using clinical expertise, CPT/ICD coding knowledge, CMC guidelines, and client-specific policies.
Review prepay medical claims and associated medical records for compliance and accuracy.
Apply CPT guidelines, reimbursement policies, health plan requirements, and contract terms during clinical claim review.
Participate in regulatory, client, provider, and legal meetings to support claim resolution and reduce provider abrasion.
Analyze data, manage claim investigations, and collaborate with cross-functional teams for issue resolution.
Conduct claim inventory monitoring to meet performance guarantees and quality benchmarks.
Support special projects, prospective reviews, and reporting initiatives as directed by business or client needs.
Work independently and act as a resource for junior team members.
Coordinate tasks and support operational adjustments aligned with organizational directives and dynamic business environments.
Maintain strict adherence to federal and state compliance guidelines and organizational policies.
Required Qualifications
Medical degree in BHMS, BAMS, BUMS, BPT, or MPT.
Bachelor’s or Master’s degree in Pharmacy (B.Pharm/M.Pharm).
B.Sc. Nursing or BDS with a minimum of 1 year corporate experience.
Certified Professional Coder (CPC) – mandatory.
Experience with CPT and ICD coding or ability to pass AAPC CPC certification.
Minimum 6 months to 3+ years of experience as a certified coder or within clinical operations.
Strong analytical skills, high attention to detail, and quality-focused approach.
Ability to work with minimal supervision and manage multiple priorities.
Preferred Qualifications
Experience in medical claims processing.
Knowledge of health insurance, US healthcare systems, and managed care frameworks.
Familiarity with medical records and clinical documentation standards.
Understanding of healthcare compliance, reimbursement, and payer policies.
About UnitedHealth Group
UnitedHealth Group focuses on helping people live healthier lives and improving the healthcare system for all. The organization is committed to promoting equitable care, reducing health disparities, and building inclusive work environments that reflect the diverse communities it serves.
Additional Details
Business Segment: Optum
Employee Status: Regular
Travel: No
Overtime Status: Exempt
Telecommuter Position: No
Schedule: Full-Time, Day Job
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China | Quarry Bay |Hubei :
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