Clinical Investigator

About the Role

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best.

Key Responsibilities

• Investigate, recover, and resolve all types of claims.
• Undertake recovery and resolution for health plans, commercial customers, and government entities.
• Initiate telephone calls to members, providers, and other insurance companies to gather coordination of benefits data.
• Investigate and pursue recoveries and payables on subrogation claims and file management.
• Process recovery on claims.
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance.
• Conduct contestable investigations to review medical history.
• Monitor large claims, including transplant cases.
• Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis codes, CMC guideline along with referring to client specific guidelines and member policies.
• Assist the prospective team with special projects and reporting.
• Work is frequently completed without established procedures.
• Works independently.
• May act as a resource for others.
• May coordinate others' activities.
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives.

Requirements & Tech Stack

• Certified coder through AAPC.
• Certifications accepted: CPC Only.
• Extensive work experience within own function.
• Proven attention to detail & Quality focused.
• Proven good Analytical & comprehension skills.
• Specialty coding such as E&M, surgery, anesthesia etc., but not only HCC (if not a medical graduate).

Qualifications

• Graduation - Any Graduate.
• BHMS/BAMS/BUMS/BPT/MPT (preferred).
• B.Sc. Nursing and BDS with 1 year of corporate experience.
• > 1 Year of experience (if not a medical graduate).
• Claims processing experience (preferred).
• Health Insurance knowledge, managed care experience (preferred).
• Knowledge of US Healthcare and coding (preferred).
• Medical record familiarity (preferred).