Clinical Investigator Full Time

Position Description
Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that’s improving the lives of millions. Here, innovation isn’t about another gadget, it’s about making health care data available wherever and whenever people need it, safely and reliably. There’s no room for error. Join us and start doing your life’s best work.(sm)

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/deny claims & Identify provider aberrant behavior patterns. The associates prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/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 the 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 & 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 car

Primary Responsibilities:

Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/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
Required Qualifications:

Medical degree – BHMS/BAMS/BUMS/BPT/MPT/BDS/MDS/ B.Sc. Nursing (Please do not apply if you are not a Medical Graduate, and Results awaited candidates will not be accepted)
0-2 years of overall experience (Medical Freshers can apply)
Good knowledge on MS Word and MS Excel
Attention to detail and Quality focused

Preferred Qualifications:

Knowledge of US Healthcare and coding
High Attention to detail which translates to 100% quality of work performed
Flexibility; ready to accommodate the working hours and working days depending on the Business Need
Ready to support the business during peak volumes as & when needed
Good written and verbal communication skills
Team player
Ability to work independently without close supervision
Good analytical skills; ability to understand the mistakes and correct the same

Careers with Optum. Here’s the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world’s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life’s best work.(sm)

Job Keywords: Clinical Investigator, Medical, Noida, Uttar Pradesh, Hyderabad, Telangana

Tagged as: general / other software