Senior 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.

Primary Responsibilities:

• This process works on identifying discrepancies between medical records and billed services for complex and high value claims by identifying Up-coding, Unbundling, Duplication, and Misrepresentation of services. Keen eye for detail. Knowledge of CPT/ diagnosis codes, CMC guideline along with referring to client specific guidelines and member policies
• 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
• 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:

• This will be a lateral movement for SG 23
• Should not be on any active CAP or PIP
• Performance Rating of ME 3 & Above in the Common review   

Required Qualifications:

• Medical degree – BHMS/BAMS/BUMS/BPT/MPT/B.Sc. Nursing 
• Knowledge of US Healthcare and coding desirable  
• Proven attention to detail & Quality focused
• Good Analytical & comprehension skills
• Basic Computer Skills 

Preferred Qualifications:

• 6+months of clinical review experience
• Claims processing experience
• Extensive knowledge on ISET/UNET/FACETS/COSMOS platform used to perform research as part of the clinical investigation process
• Medical record familiarity 
• Knowledge of ICD-10  
• Intermediate skill level with MS Office  

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.