Clinical Investigator

Job Title: Clinical Investigator/Medical Coder

Experience: Fresher/Experience(1-3years)

Qualification: Any Graduate (BHMS/BAMS/BUMS/BPT/MPT Preferred)

Certification: CPC (AAPC Certified) Mandatory

Location: Chennai, Noida, Hyderabad

Role Overview

We are seeking a detail-oriented Clinical Investigator to investigate, review, and resolve healthcare claims by identifying potential fraud, abuse, billing inaccuracies, and coding discrepancies. The ideal candidate will possess strong expertise in medical coding, claims investigation, US healthcare, medical records review, and compliance.

This role involves conducting clinical investigations, reviewing medical documentation, validating coding accuracy, ensuring compliance with healthcare regulations, and supporting claim resolution activities while maintaining the highest quality and accuracy standards.

Key Responsibilities

Clinical Investigation

• Investigate healthcare claims to identify potential fraud, abuse, billing errors, and inappropriate claim submissions.
• Review medical records, clinical documentation, and claim details to validate coding accuracy and reimbursement eligibility.
• Analyze medical history and supporting documentation to determine claim validity.
• Monitor and investigate high-value or complex claims when required.

Medical Coding Review

• Review CPT, ICD, HCPCS, diagnosis, and procedure codes for coding accuracy.
• Apply coding guidelines and reimbursement policies during claim investigations.
• Ensure compliance with coding standards and regulatory requirements.
• Identify coding discrepancies and recommend appropriate resolutions.

Claims Investigation & Resolution

• Investigate, recover, and resolve healthcare claims across commercial and government health plans.
• Coordinate claim recovery and reimbursement activities where applicable.
• Support claim adjudication through detailed clinical and coding analysis.
• Document investigation findings and maintain accurate case records.

Compliance & Quality

• Ensure adherence to healthcare regulations, reimbursement policies, and contractual obligations.
• Maintain compliance with applicable state and federal healthcare requirements.
• Follow established quality standards and investigation protocols.
• Support audit readiness through accurate documentation and reporting.

Collaboration & Stakeholder Support

• Work closely with claims, coding, quality, and clinical teams to resolve investigation cases.
• Provide guidance on coding-related issues when required.
• Support reporting, special projects, and continuous improvement initiatives.
• Coordinate activities and share knowledge with team members as needed.

Documentation & Reporting

• Maintain complete investigation records and supporting documentation.
• Prepare investigation summaries and case reports.
• Ensure accurate and timely documentation of investigation outcomes.
• Track case progress and maintain required productivity and quality metrics.

Required Qualifications

Education

• Any Graduate.

Preferred qualifications:

• BHMS
• BAMS
• BUMS
• BPT
• MPT
• B.Sc. Nursing or BDS with minimum 1 year of corporate healthcare experience.

Certification

• AAPC Certified Professional Coder (CPC) – Mandatory
• Only CPC certification will be considered.

Experience

• Minimum 1 year of experience in Medical Coding or Clinical Investigation.
• Experience in specialty coding such as:
• Evaluation & Management (E&M)
• Surgery
• Anesthesia
• Multi-specialty coding
• Experience beyond HCC coding is preferred.

Preferred Skills

• US Healthcare knowledge.
• Claims processing experience.
• Health Insurance and Managed Care experience.
• Medical records review.
• Clinical documentation analysis.
• Healthcare reimbursement guidelines.
• Fraud, Waste & Abuse (FWA) investigations.
• Strong analytical and problem-solving skills.
• Excellent attention to detail and quality focus.

Key Competencies

• Clinical Investigation
• Medical Coding (CPC)
• CPT, ICD & HCPCS Coding
• Claims Investigation
• Claims Processing
• Medical Record Review
• US Healthcare
• Health Insurance
• Managed Care
• Compliance & Regulatory Guidelines
• Fraud, Waste & Abuse (FWA)
• Reimbursement Policies
• Quality Assurance
• Documentation & Reporting
• Analytical Thinking
• Problem Solving
• Attention to Detail
• Cross-functional Collaboration

Required Qualifications:

• Graduation Any Graduate, BHMS/BAMS/BUMS/BPT/MPT (preferred)
• B.Sc. Nursing and BDS with 1 year of corporate experience
• Must be a certified coder through AAPC.
• Certifications accepted - CPC Only
• Experience Range - >1 Year (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 good Analytical & comprehension skills