Senior Clinical Investigator – CPC Certified | Optum, Hyderabad, India
Job ID: 2327427 | Category: Medical & Clinical Operations | Employment Type: Full-Time
About the Role
Optum is a global healthcare organization leveraging technology and clinical expertise to improve health outcomes for millions worldwide. We are seeking a Senior Clinical Investigator – CPC Certified to join our Hyderabad team. In this role, you will directly impact patient care and healthcare operations by investigating, recovering, and resolving clinical claims, while ensuring compliance with medical, regulatory, and contractual standards.
As a Senior Clinical Investigator, you will work independently, apply medical knowledge and coding expertise, and collaborate with internal and external stakeholders to prevent fraud, optimize reimbursements, and maintain high-quality claim processing standards.
Key Responsibilities
Investigate and resolve health plan, commercial, and government claims, including prepay and subrogation claims.
Prevent payment of potentially fraudulent or abusive claims using medical expertise, CPT/ICD coding, CMC guidelines, and client-specific policies.
Review medical records, claims, and policies to ensure accurate payment decisions.
Conduct contestable investigations for complex cases, including transplant or high-value claims.
Collaborate with providers, advocates, legal teams, and clients to resolve discrepancies or provider abrasion issues.
Analyze data, monitor claim inventories, and provide reporting for regulatory and internal stakeholders.
Perform additional projects as required, demonstrating independent problem-solving and analytical skills.
Ensure adherence to state and federal compliance policies, reimbursement regulations, and contractual obligations.
Required Qualifications
Medical degree (BHMS, BAMS, BUMS, BPT, MPT) or Pharmacy degree (B Pharma / M Pharma) or B.Sc. Nursing / BDS with 1 year of corporate experience.
Certified Professional Coder (CPC) with CPT & ICD coding knowledge, or eligibility to pass AAPC CPC Certification.
6 months to 3+ years of experience in clinical coding or medical claim investigation.
Strong attention to detail, quality-focused, with excellent analytical and comprehension skills.
Preferred Qualifications
Experience in claims processing, health insurance, and managed care.
Familiarity with US healthcare systems and medical records.
Proven ability to work independently and coordinate activities when needed.
Why Join Optum
Make a tangible impact on healthcare delivery and patient outcomes on a global scale.
Work in a diverse, inclusive, and equitable environment where every employee’s contribution is valued.
Opportunities for career growth, skill development, and participation in impactful clinical and operational projects.
Be part of an organization committed to improving access to care, reducing health disparities, and promoting sustainability.
Location: Hyderabad, Telangana, India
Schedule: Full-time, Day Shift | Travel: None required
Employment Type: Regular, Exempt
Equal Opportunity Employer
Optum provides equal employment opportunities to all qualified candidates without regard to race, gender, sexual orientation, age, religion, disability, or any other legally protected status.
Apply Now to advance your career as a Senior Clinical Investigator while contributing to improved healthcare outcomes globally.
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