Clinical Investigator

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 care
- Are not fairly priced

**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
- 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/BDS
- Knowledge of US Healthcare and coding desirable
- Attention to detail & Quality focused
- Good knowledge on MS - Word & MS - Excel

**Preferred Qualifications**:

- 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. He should have the 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)