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Role & Responsibilities
• Review high-value and complex medical claims for up-coding, unbundling, duplication, and misrepresentation
• Prevent fraudulent, abusive, and non-compliant claim payments
• Apply CPT and diagnosis coding knowledge during claim investigations
• Ensure compliance with CMC guidelines, benefit plans, and client-specific policies
• Identify provider aberrant behavior and risk patterns
• Support reporting, audits, and special investigative projects
• Maintain adherence to state and federal healthcare regulations
Qualification
• BPT / MPT
• BHMS / BAMS / BUMS
• BDS / B.Sc Nursing (minimum 1 year corporate experience mandatory)
Experience
• 6 months – 4 years in healthcare, claims review, or medical auditing roles
Skills
• Strong analytical and investigation skills
• Understanding of healthcare documentation and billing systems
• High attention to detail and quality orientation
• Good communication and reporting skills
About the Company
Optum is a global healthcare and analytics organization delivering data-driven insights, technology, and services to improve healthcare quality, efficiency, and patient outcomes worldwide.