Senior Clinical Investigator – CPC Certified
Location: Hyderabad, Telangana, India
Job Category: Medical & Clinical Operations
Employment Type: Full-Time
Job Overview
We are hiring a Senior Clinical Investigator – CPC Certified to support medical claims investigation, fraud prevention, and regulatory compliance within the US healthcare and insurance domain. This role requires strong clinical knowledge, coding expertise, and the ability to independently evaluate complex medical claims while ensuring adherence to federal, state, and client-specific policies.
The position offers an opportunity to work at the intersection of clinical expertise, healthcare analytics, and compliance within a global healthcare organization.
Key Responsibilities
Review and investigate pre-payment medical claims to identify potentially fraudulent, abusive, or incorrect payments
Utilize clinical expertise and in-depth knowledge of CPT, ICD, and CMC guidelines, along with client-specific policies, to determine claim accuracy
Analyze medical records and supporting documentation to validate medical necessity and reimbursement eligibility
Participate in regulatory and client meetings, providing clinical insights and claim resolution support
Collaborate with providers, advocates, and legal teams to resolve claim disputes and provider abrasion cases
Monitor claim inventories to ensure adherence to performance guarantees and turnaround timelines
Ensure strict compliance with state and federal regulations, reimbursement policies, and contractual obligations
Support special projects, audits, reporting, and data analysis initiatives as required by the business
Work independently with minimal supervision and act as a subject matter resource for junior team members when needed
Required Qualifications
Education
Candidates must possess one of the following qualifications:
Medical degrees such as BHMS, BAMS, BUMS, BPT, MPT
B.Pharm or M.Pharm
B.Sc. Nursing or BDS with at least 1 year of corporate experience
Certification
Certified Professional Coder (CPC) – mandatory
Strong working knowledge of CPT and ICD coding standards
AAPC CPC certification required
Experience
6 months to 3+ years of relevant experience in medical coding, clinical investigation, or healthcare claims review
Minimum 6 months of experience as a certified coder
Experience working independently on complex claim investigations
Skills & Competencies
Strong analytical, comprehension, and problem-solving abilities
High attention to detail with a strong focus on quality and accuracy
Ability to interpret medical records and clinical documentation effectively
Excellent written and verbal communication skills
Preferred Qualifications
Prior experience in claims processing or health insurance operations
Knowledge of US healthcare systems, managed care, and reimbursement workflows
Familiarity with medical records, utilization review, and payer guidelines
Why Join This Role
This position offers exposure to high-impact healthcare operations, enabling professionals to contribute directly to improving payment accuracy, fraud prevention, and patient care outcomes. You will work in a structured yet evolving environment that values clinical judgment, compliance, and analytical excellence.
About the Organization
Optum, part of UnitedHealth Group, is a global healthcare organization committed to improving health outcomes through technology-enabled care solutions. The organization emphasizes inclusion, ethical practices, and equitable healthcare delivery across diverse populations.
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