Senior Clinical Investigator – CPC Certified
Location: Hyderabad, Telangana, India
Company: Optum (UnitedHealth Group)
Job Category: Medical & Clinical Operations
Job Type: Full Time
Experience Required: 6 months – 3+ years
Requisition Number: 2327427
Position Overview
Optum, a global leader in healthcare services and technology, is hiring a Senior Clinical Investigator (CPC Certified). This role involves clinical claim investigation, fraud waste and abuse (FWA identification), CPT/ICD code-based reviews, and ensuring compliance with medical policies and reimbursement guidelines. The position requires strong clinical knowledge and coding expertise to support accuracy in claim adjudication and payment integrity.
Key Responsibilities
Prevent payment of potentially fraudulent, abusive, or incorrect claims through clinical expertise and coding knowledge (CPT/ICD, CMC guidelines, and client-specific policies).
Review pre-payment claims with medical records to assess accuracy and compliance.
Interpret and apply CPT guidelines, reimbursement policies, contracts, and clinical rules for claim review.
Participate in regulatory and client meetings to discuss clinical review findings and process improvements.
Engage with providers, advocates, and legal teams to support resolution and reduce provider abrasion.
Analyze data and support special projects, reporting, and operational enhancements.
Continuously monitor claim inventory to meet performance guarantees.
Ensure adherence to state and federal compliance regulations.
Work independently with minimal instruction and act as a resource for other team members where needed.
May coordinate or guide the work of others within the team.
Follow all organizational policies, contractual obligations, and operational directives.
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)
Mandatory Certifications & Skills:
Certified Professional Coder (CPC) – AAPC
CPT & ICD coding experience
OR must pass AAPC CPC Certification if not already certified
Experience:
6 months to 3+ years
Experience as a certified coder (minimum 6 months)
Strong analytical, comprehension, and documentation skills
High attention to detail and quality-driven approach
Preferred Qualifications
Experience in claims processing
Knowledge of US healthcare system and managed care concepts
Understanding of health insurance processes
Familiarity with medical records and documentation review
About Optum / UnitedHealth Group
Optum, part of UnitedHealth Group, is a global healthcare organization delivering technology-enabled care solutions. The company focuses on improving access to quality care, reducing healthcare disparities, and advancing equity across healthcare systems. Optum fosters an environment built on inclusion, career development, and meaningful impact—helping employees grow while contributing to 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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