Clinical Investigator

UnitedHealth Group; Dadri; On-site; Confidential; Full time

Job summary

UnitedHealth Group is seeking professionals to investigate, recover, and resolve claims for health plans and government entities. The role involves contacting members, providers, and other insurers to gather coordination data and pursuing recoveries on subrogation cases.

You will ensure adherence to policy and contract guidelines while handling complex claim workflows. Qualifications include CPC certification and healthcare coding knowledge.

Qualifications

• Graduation - Any Graduate or healthcare related degree.
• Certified coder through AAPC; CPC preferred.
• Experience in medical coding across CPT/diagnosis codes.

Responsibilities

• Investigate, recover and resolve claims for health plans and government entities.
• Initiate calls to members, providers, and other insurers for data.
• Ensure compliance with policies and contract requirements.
• May coordinate team activities and assist on special projects.

Skills

CPC Certification

Analytical skills

Attention to detail

Healthcare knowledge

Coding knowledge

Education

Bachelor's degree or equivalent

BHMS/BAMS/BUMS/BPT/MPT or B.Sc. Nursing/BDS (preferred)

Tools

AAPC Certified coder

Job description

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
• 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 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

Eligibility

To apply to an internal job, employees must meet the following criteria:

• Minimum 12 months in the current role
• Not on Active CAP at the time of applying for the IJP
• Employees at SG 22 and SG 23 are eligible
• Employees must notify their Current Manager before applying for the IJP
• Last Common Review rating should be Meeting Expectations or Exceeding Expectations

Required Qualifications:

• Graduation - Any Graduate, BHMS/BAMS/BUMS/BPT/MPT (preferred)
• B.Sc. Nursing and BDS with 1 year of corporate experience
• Certified coder through AAPC
• Certifications accepted - CPC Only
• Experience Range - >1 Year (if not medical graduate)- specialty coding such as E&M, surgery, anesthesia etc, but not only HCC
• 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

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.