Medical Claims Auditor

The Special Investigation Unit (SIU) is a motivated collaborative team sitting at the intersection of Compliance Payment Integrity and Data Infrastructure. The SIU ensures that Clover monitors identifies and investigates instances of healthcare fraud waste and abuse (FWA). Come join us as we discover new opportunities to enhance the fight against FWA!

As a Medical Claims Auditor within our Special Investigations Unit you will play a critical role in ensuring that Clover is able to continue to build and scale a compliant effective FWA audit program. You will be joining a fast-growing and fast-moving startup at the intersection of healthcare and technology where you will have the opportunity to develop both your policy and operational skills. A successful Medical Claims Auditor will have a broad coding knowledge base including but not limited to: DME Outpatient ASC and Physician correct coding. This position will focus specifically on Medicare coding policies.

As a Medical Claims Auditor you will:

• Partner with Clinical Claims and SIU peers to review claims for billing and coding related issues on a retrospective basis that currently drive inaccurate payments to providers or indicate FWA.
• Identify control opportunities to mitigate FWA.
• Identify possible audit opportunities.
• Support annual FWA audit goals.
• Support provider conversations around FWA audit findings.
• Manage overall audit workload to ensure timely and accurate audit results.
• Work closely with senior team members and management on targeted projects and initiatives.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.

Success in this role looks like:

• By the end of your initial 90 day period you will have demonstrated a strong understanding of our review process and are able to effectively navigate through the various Clover systems.
• By 6 months you will be working autonomously on 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 coding and auditing experience experience with CMS regulations preferred.
• You have a Certified Professional Coder (CPC) or other coding certification is a plus.
• You have a strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI.
• You have experience working in a technology environment including claims systems workflow management tools Microsoft Office or Google Suite.
• You have prior experience working in health insurance; Medicare Advantage is a plus.

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.

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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 $90000$110000. Final pay is based on several factors including but not limited to internal equity market data and the applicants education work experience certifications etc.

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