CLINICAL INVESTIGATOR

Optum India; Gurgaon; On-site; INR 350,000 - 600,000; Full time

Job summary

Optum India is hiring for a claims investigations and recovery role focused on health plan claims across corporate and government accounts. You will investigate and resolve diverse claim types, pursue recoveries, and ensure compliance with policies and contracts.

The role involves coordinating with members, providers and other insurers, handling data gathering, and supporting special projects. A keen eye for detail and strong analytical abilities are essential to succeed in this dynamic

Qualifications

• Medical degree in BHMS/BAMS/BUMS/BPT/MPT
• B.Sc Nursing or BDS with 1+ years corporate experience mandatory
• 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 excellent analytical & comprehension skills
• Proven ability to work independently

Responsibilities

• Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis codes, CMC guideline along with 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
• 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 transfer or re-assignment to different work locations, changes 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

Skills

Attention to detail

Analytical skills

Independence

Quality oriented

Education

BHMS/BAMS/BUMS/BPT/MPT

B.Sc Nursing / BDS

Job description

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. Work is frequently completed without established procedures.

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
• 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

Required Qualifications

• Medical degree - BHMS/BAMS/BUMS/BPT/MPT
• B.Sc Nursing and BDS with 1+ years of corporate experience mandatory
• 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 excellent 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

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.