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 Qualified 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

📌 Medical Coder (Chennai)
🏢 Vdart Software Services Private
📍 Chennai