Investigator, SIU

At Clover Health we are committed to providing high-quality affordable and easy-to-understand healthcare plans for Americas seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each members complete health history we ensure better care at a lower costdelivering the highest value to those who need it most.

The Special Investigation Unit (SIU) is a collaborative team at the crossroads of Compliance Payment Integrity and Data Infrastructure focused on detecting and investigating healthcare fraud waste and abuse (FWA). As an Investigator youll help scale Clovers FWA audit program ensuring regulatory compliance and quality assurance. Youll develop and execute effective audit strategies to identify and report suspected FWA while growing your policy and operational expertise in a fast-paced tech-driven healthcare environment.

As an Investigator you will:

• Implement an effective audit strategy to investigate known or suspected instances of FWA.
• Support complex provider conversations around FWA audit findings.
• Prepare response letters to deliver information to providers within the regulatory timeframes set forth by the Centers for Medicare & Medicaid Services (CMS).
• Manage overall audit workload to ensure timely and accurate audit results.
• Act as a FWA subject matter expert.
• Collaborate to identify possible audit opportunities.
• Build strong working relationships with both regulatory and law enforcement agencies.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.
• Support annual FWA goals

Success in this role looks like:

• By the end of your initial 90 day period you will have demonstrated a strong understanding of our SIU case flow and are able to effectively navigate through the various Clover systems.
• By 6 months you will be working autonomously on cases and provider reviews.
• Continued success in this position anchors in on developing a deep understanding of the workflows that support our SIU cases and reviews while maintaining regulatory compliance standards.

You should get in touch if:

• You have 3 years of experience in the healthcare FWA space.
• You have experience identifying operations and process improvement efforts.
• You have an understanding of compliance & payer requirements including Medicare regulations.
• You have knowledge on fraud statutes and regulations and preferably hold certifications like CFE AHFI or similar.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally we offer a performance-based bonus program 401k matching and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical dental and vision coverage. Your health matters to us and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this we offer initiatives such as No-Meeting Fridays monthly company holidays access to mental health resources and a generous flexible time-off policy. Additionally we embrace a remote-first culture that supports collaboration and flexibility allowing our team members to thrive from any location.
• Professional Development: Developing internal talent is a priority for Clover. We offer learning programs mentorship professional development funding and regular performance feedback and reviews.

Additional Perks:

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture enabling collaboration with global teams
• Paid parental leave for all new parents
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken so weve created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise working together to solve the most complicated problem in the world: healthcare.

From Clovers inception Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths experiences perspectives opinions and backgrounds who share a passion for improving peoples lives. Diversity not only includes race and gender identity but also age disability status veteran status sexual orientation religion and many other parts of ones identity. All of our employees points of view are key to our success and inclusion is everyones responsibility.

#LI-REMOTE

Pursuant to the San Francisco Fair Chance Ordinance we will consider for employment qualified applicants with arrest and conviction records.We are anE-Verify company.

A reasonable estimate of the base salary range for this role is $83000 to $125000. Final pay is based on several factors including but not limited to internal equity market data and the applicants education work experience certifications etc.

#LI-Remote