Senior Clinical Investigator - CPC Certified

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.

Positions in this function are responsible for investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities. May include initiating 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. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases.

Primary Responsibilities:

• 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
• Reviews prepay claims with corresponding medical records to determine payment accuracy
• Reviews applicable policies, CPT guidelines and contracts as they pertain to clinical review
• Participate in regulatory meetings with client
• Participates in meetings with providers, advocates and legal to assist with provider abrasion
• Performs additional projects as needed by the business or Client analyzes data meets with internal and external stakeholders as necessary for resolution
• Continuous monitoring of claim inventory in order to adhere to performance guarantees
• Adherence to state and federal compliance policies and contract compliance
• 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 (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regard 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 Pharma/M Pharma
• B.Sc. Nursing and BDS with 1 year of corporate experience
• Certified Professional Coder - CPC
• CPT & ICD coding experience or must pass AAPC CPC Certification
• Experienced certified coder (6+ months)
• Experience Range - 06 months - 3+ years
• Extensive work experience within own function.
• Proven attention to detail & Quality focused
• Proven good Analytical & comprehension skills

Preferred Qualifications:

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