Clinical Investigator

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. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

This process works on identifying Fraud, Waste and Abuse between medical records and billed services for complex and high value claims by identifying Up-coding, Unbundling, Duplication, and Misrepresentation of services. They approve or deny claims and Identify provider aberrant behavior patterns. The associates prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT or diagnosis codes, CMS guideline along with referring to client specific guidelines and member policies.

Fraud is intentionally misrepresenting or concealing facts to obtain something of value. The complete definition has three primary components:

• Intentional dishonest action or misrepresentation of fact
• Committed by a person or entity
• With knowledge that dishonest action or misrepresentation could result in an inappropriate gain or benefit

This definition applies to all persons and all entities. However, there are special rules around intentional misrepresentations to Government programs such as Medicare and Medicaid, or TRICARE.

Waste includes inaccurate payments for services, such as unintentional duplicate payments, and can include inappropriate utilization and/or inefficient use of resources.

Abuse includes any practice that results in the provision of services that:

• Are not medically necessary
• Do not meet professionally recognized standards for health care
• Are not fairly priced

Primary Responsibilities:

• Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT or diagnosis codes, CMS guideline along with referring to client specific guidelines and member policies
• Adherence to state and federal compliance policies and contract compliance
• Assist the prospective team with special projects and reporting
• Coordinate with all team members and share recent process related updates
• Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

Required Qualifications:

• Medical degree - BHMS/BAMS/BUMS/BPT/MPT
• B.Sc Nursing and BDS with 1+ years of corporate experience
• 6+ months of experience (Fresher's in BPT / MPT / BHMS/ BAMS/ BUMS can also apply)
• Extensive work experience within own function
• Proven attention to detail & quality focused
• Proven good analytical & comprehension skills
• Proven ability to work independently

Preferred Qualifications:

• Claims processing experience
• Health Insurance knowledge, managed care experience
• Knowledge of US Healthcare and coding
• Medical record familiarity