Senior Clinical Investigator – CPC Certified | Hyderabad, Telangana, India
Location: Hyderabad, Telangana, India
Department: Medical & Clinical Operations
Employment Type: Full-Time
Experience Required: 6 months – 3+ years in clinical investigation or certified coding
Function: Clinical Operations, Medical Coding, Claims Management
About Optum
Optum, a global leader in health services, leverages technology and clinical expertise to help millions of people live healthier lives. Our teams connect individuals with care, pharmacy benefits, data, and resources to optimize health outcomes. We are committed to fostering an inclusive culture, supporting career development, and providing comprehensive benefits, all while making a tangible impact on the communities we serve globally.
At Optum, every role contributes directly to improving healthcare delivery, enhancing patient outcomes, and supporting health optimization initiatives across diverse populations.
Position Overview
We are seeking a Senior Clinical Investigator – CPC Certified to join our Medical & Clinical Operations team in Hyderabad. The ideal candidate will combine clinical knowledge, medical coding expertise, and analytical skills to review, investigate, and resolve complex claims for health plans, commercial clients, and government entities.
This role is pivotal in ensuring compliance with federal and state regulations, accurate claim adjudication, and effective collaboration with providers and internal stakeholders.
Key Responsibilities
Review prepay claims and corresponding medical records to assess payment accuracy
Utilize clinical expertise, CPT/ICD codes, and organizational guidelines to prevent fraudulent or abusive claims
Ensure adherence to state and federal compliance policies, reimbursement guidelines, and contractual obligations
Conduct contestable investigations, including medical history review, to validate claim legitimacy
Collaborate with providers, advocates, and legal teams to address claim issues and provider concerns
Support data analysis, reporting, and special projects for the Medical & Clinical Operations team
Monitor claim inventory to meet performance guarantees and quality benchmarks
Act as a resource and coordinate activities for junior team members as needed
Work independently, managing complex cases without established procedures
Comply with company policies, directives, and any changes in work location, team, or schedule
Required Qualifications
Medical or Healthcare Background: BHMS, BAMS, BUMS, BPT, MPT, B Pharma/M Pharma, B.Sc Nursing, or BDS
Certification: Certified Professional Coder (CPC)
Coding Experience: CPT & ICD coding experience or must pass AAPC CPC Certification
Experience Range: 6 months – 3+ years in clinical investigation, claims review, or medical coding
Strong analytical, comprehension, and quality-focused skills
Proven attention to detail and ability to work independently on complex claims
Preferred Qualifications
Previous experience in claims processing or managed care
Knowledge of US Healthcare system, insurance processes, and coding standards
Familiarity with medical records review and documentation
Why Join Optum?
Contribute to a mission-driven organization improving healthcare delivery globally
Work in a high-impact role ensuring accuracy, compliance, and optimal patient outcomes
Gain exposure to international healthcare practices, coding standards, and regulatory frameworks
Be part of an inclusive culture that values diversity, equity, and career growth
At Optum, we are committed to removing barriers to health equity and enabling every individual to achieve their healthiest life possible, while upholding the highest standards of quality, integrity, and patient safety.
Apply now to join our team and make a difference in healthcare globally.
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