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 Skilled 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 Records Coder (Chennai)
🏢 Vdart Software Services Private
📍 Chennai