Optum, part of UnitedHealth Group, is hiring for the Clinical Investigator position in Noida, Uttar Pradesh. The role focuses on investigating potentially fraudulent or abusive healthcare claims, reviewing medical information, applying medical coding knowledge and ensuring compliance with reimbursement policies.

Candidates with medical, nursing, physiotherapy or other graduate qualifications, along with relevant coding experience or CPC certification as required, can review the eligibility criteria below.

Job Details

Position: Clinical Investigator

The Clinical Investigator supports healthcare claims investigation and recovery activities, using medical expertise and coding knowledge to identify potentially fraudulent or abusive claims and ensure compliance with applicable policies.

Key Responsibilities

• Identify potentially fraudulent or abusive claims using medical expertise, CPT and diagnosis codes, CMC guidelines, client-specific guidelines and member policies.
• Ensure compliance with state and federal regulations and contractual requirements.
• Support special projects and reporting activities for the prospective team.
• Investigate healthcare claims and support claims recovery and resolution activities.
• Work independently on assignments and serve as a resource for other team members when required.

Eligibility and Qualifications

Optum lists the following educational qualifications and experience requirements:

• Any graduate degree.
• BHMS, BAMS, BUMS, BPT or MPT are preferred qualifications.
• B.Sc. Nursing and BDS candidates must have at least one year of corporate experience.
• AAPC-certified medical coders with CPC certification only are accepted under the stated certification criteria.
• Candidates who are not medical graduates must have more than one year of experience in specialty coding, such as Evaluation and Management (E&M), surgery or anaesthesia; experience limited to HCC coding does not meet this stated requirement.

Required Skills

• Strong analytical and comprehension skills.
• Excellent attention to detail and a quality-focused approach.
• Knowledge of medical terminology and CPT/diagnosis coding.
• Ability to investigate claims and apply relevant medical and reimbursement guidelines.
• Ability to work independently and handle assignments with limited established procedures.

Preferred Qualifications

• Claims processing experience.
• Knowledge of health insurance and managed care.
• Understanding of US healthcare and medical coding.
• Familiarity with medical records.
• Relevant functional experience.

Application Details

Application Link