Positions in this function are responsible for investigating, recovering and resolving all types of claims as well as recovery and resolution for health plans, commercial customers and government entities. May include initiating telephone calls to members, providers and other insurance companies to gather coordination of benefits data. Investigate and pursue recoveries and payables on subrogation claims and file management. Process recovery on claims. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance. May conduct contestable investigations to review medical history. May monitor large claims including transplant cases. Work is frequently completed without established procedures

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
- 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 workplace, 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
- B.Sc Nursing and BDS with 1+ years of corporate experience
- 6+ months of experience (Fresher''s in BPT / MPT / BHMS/ BA

📌 Clinical Investigator (Gurugram)
🏢 Optum
📍 Gurugram