Job Title: Senior Clinical Investigator – CPC Certified
Job Category: Medical & Clinical Operations | Healthcare Claims | Clinical Audit
Location: Hyderabad, Telangana, India
Employment Type: Full-Time | Regular
Experience Required: 6 Months to 3+ Years
Requisition ID: 2327427
ThePharmaDaily.com presents an excellent career opportunity for a Senior Clinical Investigator (CPC Certified) to join a globally recognized healthcare organization. This role is ideal for medical and pharmacy professionals with strong expertise in clinical review, medical coding, and healthcare claims investigation within the US healthcare ecosystem.
As a Senior Clinical Investigator, you will play a critical role in preventing inaccurate, abusive, or fraudulent claim payments, ensuring compliance with regulatory standards, reimbursement policies, and contractual requirements while supporting health plans, commercial clients, and government entities.
Investigate, review, and resolve complex healthcare claims, including prepay and post-pay reviews
Prevent improper payments by applying clinical knowledge, CPT and ICD coding expertise, and medical necessity guidelines
Review medical records, policies, CPT guidelines, and contractual terms to determine claim accuracy
Conduct contestable investigations, including medical history reviews where applicable
Initiate and manage recovery processes for subrogation and overpaid claims
Coordinate with providers, members, insurance companies, and internal stakeholders to gather required information
Participate in regulatory and client meetings to support compliance and resolution strategies
Monitor high-value and complex claims, including transplant-related cases
Maintain continuous oversight of claim inventories to meet performance and turnaround benchmarks
Support special projects, reporting initiatives, and cross-functional activities as assigned
Act as a subject matter resource for junior team members and assist in activity coordination when required
Ensure strict adherence to state, federal, and client-specific compliance and reimbursement policies
Medical or healthcare qualification such as:
BHMS / BAMS / BUMS / BPT / MPT
B.Pharm / M.Pharm
B.Sc. Nursing or BDS with minimum 1 year of corporate experience
Active AAPC Certified Professional Coder (CPC) certification
Hands-on experience with CPT and ICD coding or successful completion of CPC certification
Minimum 6 months to 3+ years of experience in clinical investigation, medical coding, or healthcare claims review
Strong analytical, comprehension, and decision-making skills
High attention to detail with a quality-focused approach
Ability to work independently in dynamic and evolving work environments
Experience in healthcare claims processing or recovery operations
Knowledge of US health insurance, managed care, and reimbursement models
Familiarity with medical records, utilization review, and clinical documentation standards
Exposure to fraud, waste, and abuse (FWA) investigations
Contribute directly to improving healthcare integrity and payment accuracy
Work in a collaborative, inclusive, and growth-oriented environment
Gain exposure to US healthcare systems, payer policies, and regulatory frameworks
Advance your career in clinical operations, claims integrity, and healthcare analytics
This opportunity is with a leading global healthcare and technology organization dedicated to improving health outcomes through innovation, data-driven insights, and patient-centered solutions. The organization is deeply committed to diversity, equity, compliance, and creating a healthcare system that works better for everyone.
Gujarat :
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Delhi | India | New Delhi | PAN-India |Assam :
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Pondicherry (Puducherry) |Jharkhand :
Ranchi |Sikkim :
Rangpo |India :
Siliguri |Illinois :
Abbott Park | Bloomingdale | Champaign | Chicago | Deerfield | Glenview | Lake Forest | Lombard | Naperville | Norridge | Park RIdge | Round Lake |Maryland :
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Anchorage | Barrow | Bethel | Juneau | Sitka | Wrangell |Massachusetts :
Andover | Billerica | Boston | Cambridge | Devens | Lexington | Massachusetts | Medford and Somerville | Rockland |Wisconsin :
Appleton | Kenosha | Pleasant Prairie | Portage | Waukesha |United states :
Arizona | Buffalo Grove | Clayton | Downers Grove | fairmont | Georgia | Keene | Michigan | Mt. Pleasant | New Jersy | OH | Piedmont | Salisbury | United States | Whitesboro | Winston-Salem |Georgia :
Atlanta | Augusta | Rome |Maine :
Bangor | Brewer |New Jersey :
Basking Ridge | Bloomfield | Branchburg Township | Bridgewater | Brunswick | Burlington | Charlotte | Clark | Cranbury | Dunellen | East Brunswick | Edison | Fairfield | Far Hills | Flemington | Hackensack | Hopewell | Indianapolis | Jersey City | Linden | Livingston | Lyndhurst | Mahwah | Monmouth Junction | Montville | Mount Arlington | Newark | New Brunswick | Nutley | Paramus | Parsippany | Passaic | Paterson | Peapack-Gladstone | Pine Brook | Piscataway Township | Plainsboro | Princeton Junction | Rahway | Raritan | Somerset | Somerville | South Plainfield | Sparta | Summit | Titusville | Trenton | Warren Grove | Westfield | West Orange | Wharton | Whippany |Ohio :
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Duluth | Eden Prairie | Fridley | Hibbing | Maple Grove | Minneapolis and St. Paul, Minnesota. | Minnetonka | St.Paul |Kentucky :
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Bulgaria | Vedant |Denmark :
Copenhagen | Denmark |Europe :
Europe | France | Latvia | Lendava | Leuven | Poland | Slovenia | Spain |Finland :
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Swords |Republic of China :
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China | Quarry Bay |Liaoning :
Dalian |Zhejiang :
Hangzhou |Tokiyo :
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Shanghai Shi |Hubei :
Wuhan |Capital of Netherland :
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Netherlands |Remote Australia :
Arkansas | Remote Australia |New South Wales :
Ballina | Sydney |Republic of Western Australia :
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South Yarra |United Kingdom :
England | Harlow | Leeds | London | Maidenhead | Salt Lake City | Stevenage | Stirling | United Kingdom |North Yorkshire :
Harrogate |South Yorkshire :
Sheffield |Oxfordshire :
Witney |Ontario :
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Estonia | Tartu |Harju County (Maakond) :
Tallinn |Hà Nội :
Hà Nội | Hanoi |Ho Chi Minh :
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Italy |Lombardy :
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Oulu |Southwest Finland (Varsinais-Suomi) :
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Seoul |Kazakhstan :
Almaty |Republic of Thailand :
Bangkok |Israel :
Tel Aviv | Yavne | Netanya | Kfar Saba | Be'Er Sheva |Remote :
Springville | Belgium | Xzagreb | Slovakia | Bountiful | Regulatory Labeling Manager (NA and LATAM Only) | Bishop | Castlebar | Lenexa | Leinster | Nairobi | Riga | McFarland | Remote - Europe | Lousiana | Ireland | Green Way | Texas | Faridabad | Blue Bell | Remote, USA | Switzerland | Manipal | Medan | Tulsa | French | Victoria | Zaragoza | Remote - South America (Latin Americal) | Minnesota | Hungary | Remote - Africa | Melbourne | Remote - Middle East | Thailand | Remote | Hammond |Republic of Colombia :
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New Mexico | Ciudad de México |Dubai :
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Rabigh | Jeddah | Najran | King Abdullah Economic City | Riyadh | Khulais |Kuala Lumpur :
Kuala Lumpur |Kyiv Oblast :
Kyiv |Lima Region :
Lima |France :
Lyon | Paris |South Africa :
South Africa | Midrand |Nišava District :
Niš |Bohemia :
Prague |Chile :
Santiago |Bosnia and Herzegovina :
Sarajevo |Singapore :
Singapore |Sofia City :
Sofia |Sweden :
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