Clinical Investigator

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

Required Qualifications:

• Graduation - Any Graduate, BHMS/BAMS/BUMS/BPT/MPT (preferred)
• B.Sc. Nursing and BDS with 1+ years of corporate experience
• Certified coder through AAPC
• Certifications accepted - CPC Only 
• 1+ years of experience (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 excellent analytical & comprehension skills

Preferred Qualifications:

• Claims processing experience
• Health Insurance knowledge, managed care experience
• Knowledge of US Healthcare and coding
• Medical record familiarity