Medical Claims Auditor

Clover Health; Oregon; Híbrido; USD 92.000 - 120.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Equity opportunities

401k matching

No-Meeting Fridays

Remote-first culture

Paid parental leave

ESPP

Descripción de la vacante

Clover Health is hiring a Medical Claims Auditor in the Special Investigations Unit (SIU) to ensure compliant Medicare coding and prevent improper payments. You will review claims for billing issues, leverage AI tools to detect anomalies, and collaborate with Data Science and Engineering to validate AI-flagged cases while driving continuous improvement in the audit program.

You will also engage with providers to discuss FWA findings, manage workloads to meet strict prepayment timelines, and

Formación

• 3+ years coding and auditing experience; CMS regulations preferred.
• Certified Professional Coder (CPC).
• Strong knowledge of CMS Manual of Correct Codification (CCI) rules.
• Experience in a technology environment including claims systems and workflow tools (MS Office or Google Suite).
• Health insurance experience; Medicare Advantage is a plus.

Responsabilidades

• Partner with Clinical, Claims, and SIU to review claims for billing and coding issues on prepayment and retrospective bases.
• Leverage internal AI tools and predictive models to identify anomalous billing patterns and opportunities for audits.
• Collaborate with Data Science and Engineering to validate AI-flagged claims and provide coding feedback.
• Identify control opportunities to mitigate FWA and implement systemic prepayment edits.
• Manage audit workload to ensure timely and accurate results within prepayment turnaround times.
• Communicate findings to providers in clear, actionable terms and support remediation.
• Work with senior team on targeted projects and initiatives.

Conocimientos

Coding

Auditing

CMS regulations

CPC

CCI rules

Claims systems

MS Office / Google Suite

Medicare Advantage

Herramientas

Claims systems

Workflow tools

Microsoft Office

Google Suite

Descripción del empleo

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 both a prepayment and retrospective basis to prevent inaccurate payments to providers and disrupt FWA before funds leave the door.
• Leverage internal AI tools and predictive models to proactively identify anomalous billing patterns, emerging trends, and new opportunities for targeted prepayment audits.
• Collaborate directly with our Data Science and Engineering teams to validate AI-flagged claims in the prepayment queue, providing expert coding feedback to continuously train and refine our machine learning models.
• Identify control opportunities to mitigate FWA, focusing heavily on implementing systemic prepayment edits.
• Identify possible audit opportunities through AI-assisted data analysis and manual case identification.
• Support annual FWA audit goals by prioritizing high-value reviews.
• Support provider conversations around FWA audit findings, translating complex data, AI insights, and prepayment denials into clear, actionable compliance feedback.
• Manage overall audit workload to ensure timely and accurate audit results within strict prepayment turnaround times.
• 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 and supporting further case/opportunity identification.
• 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 are a Certified Professional Coder (CPC).
• 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 we've 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 Clover's 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 people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one's identity. All of our employee's points of view are key to our success, and inclusion is everyone's responsibility.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.Final pay is based on several factors including but not limited to internal equity, market data, and the applicant's education, work experience, certifications, etc.A reasonable estimate of the base salary range for this role is:$92,300—$120,000 USD