Walk-in || Senior Clinical Investigator

About Us:

UnitedHealth Group is a diversified health and well-being company dedicated to making healthcare systems work better. The company directs its resources into designing products, providing services, and applying technologies that improve access to health and well-being services, simplify the healthcare experience, promote quality and make healthcare more affordable. This primarily consists of Health Benefits and Health Services.

Health Service is now being provided under Optum brand. Optum was established in 2011, when UnitedHealth Group unified its market-leading services and capabilities into a single, integrated company focused on solving the biggest and most complex challenges facing health care. Optum works collaboratively across the health system to improve care delivery, quality and cost-effectiveness, and focuses on three key drivers of transformative change: engaging the consumer, aligning care delivery and modernizing the health system infrastructure.

Join us today for an inspired and purposeful mix of professional growth opportunities and personal rewards.

Job Description

• This process works on identifying Fraud, Waste and Abuse between claim form and billed services for complex and high value claims by identifying 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 knowledge of CPT/ diagnosis codes, CMC guideline along with referring to client specific guidelines and member policies.
• Cross checks complex medical records and takes decisions that claims suitable for Prepay review or not.
• Prevent the payment of potentially fraudulent and/or abusive claims utilizing 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 and may project innovative idea for process improvement.
• 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 dishonest action or misrepresentation could result in an inappropriate gain or benefit
• This definition applies to all people 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

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 - MBBS/BHMS/BAMS/BUMS/BPT/MPT/BDS/ BSC Nursing
• 1+ years of corporate experience. Desirable candidates should have knowledge of US Healthcare, CPT/HCPCS codes and claim adjudication.
• Attention to detail & Quality focused.
• Must be a graduate and minimum 1+ year of US healthcare experience in claims
• Good knowledge on MS - Word & MS Excel.

Preferred Skills and Expertise

• 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.Role & responsibilities

Preferred candidate profile