Optum is a leading global healthcare organization that leverages cutting-edge technology to improve health outcomes for millions. Our mission is to help people live healthier lives by providing integrated care, pharmacy benefits, and data-driven solutions. At Optum, we foster an inclusive work environment with comprehensive benefits and career growth opportunities. Join us in making a meaningful impact on global health.
Job Description
As a Clinical Investigator, you will play a crucial role in identifying discrepancies between medical records and billed services for high-value claims. Your responsibilities will include detecting upcoding, unbundling, duplication, and misrepresentation of services while ensuring compliance with medical coding standards and client-specific policies.
Key Responsibilities:
- Review and analyze complex medical claims to detect fraudulent or abusive billing practices.
- Utilize knowledge of CPT, ICD-10 codes, and CMC guidelines to validate claims.
- Ensure adherence to state and federal compliance policies and contract regulations.
- Maintain high attention to detail and accuracy in claim assessments.
- Collaborate with teams to prevent improper claim payments.
- Adapt to changing business needs, including shifts, policy updates, and work reassignments.
Qualifications
Required:
- Medical degree (BHMS/BAMS/BUMS/BPT/MPT/B.Sc. Nursing).
- Basic understanding of US healthcare and medical coding (preferred).
- Strong analytical and comprehension skills.
- Detail-oriented with a quality-focused approach.
- Basic computer proficiency.
Preferred:
- 0 – 6+ months of clinical review experience.
- Familiarity with ISET/UNET/FACETS/COSMOS platforms.
- Prior claims processing experience.
- Knowledge of medical records and ICD-10 coding.
- Intermediate skills in MS Office (Word, Excel).
Why Join Optum?
- Global Impact: Contribute to a mission that improves healthcare worldwide.
- Inclusive Culture: Work in a diverse and supportive environment.
- Career Growth: Access to training and development programs.
- Comprehensive Benefits: Health, wellness, and financial benefits.
