Medical Claims Auditor

Clover Health; United States; Remote; USD 92,000 - 120,000; Full time

Benefits offered by this job

Competitive base salary

Equity opportunities

401k matching

Medical/dental/vision

No-Meeting Fridays

Remote-first culture

Parental leave

ESPP

Cell phone stipend

Job summary

Clover Health's Special Investigations Unit (SIU) seeks a Medical Claims Auditor to uphold a compliant FWA audit program across Medicare and payer policies. You will review claims prepayment and retrospectively, leveraging AI insights and collaboration with Clinical, Claims, and Data teams.

The role emphasizes strong coding knowledge (DME, Outpatient, ASC, Physician), CMS rules, and effective communication with providers.

Qualifications

• 3+ years of coding and auditing experience; CMS regulations preferred.
• Certified Professional Coder (CPC) credential required or preferred.
• Strong knowledge of CMS National Rules of Correct Codification and CCI tables.
• Experience with health insurance/Medicare Advantage is a plus.
• Experience in technology environments including claims systems and workflow tools.

Responsibilities

• Review claims for billing and coding issues on prepayment and retrospective basis.
• Use AI tools and predictive models to identify anomalous billing patterns and opportunities for prepayment audits.
• Collaborate with Data Science and Engineering teams to validate AI-flagged claims and provide coding feedback.
• Identify controls to mitigate FWA and implement systemic prepayment edits.
• Communicate audit findings clearly to providers and internal teams; manage audit workload to meet prepayment turnaround times.

Skills

Medical coding

Auditing

Certified Professional Coder (CPC)

CMS regulations knowledge

Claims systems experience

Office/GSuite proficiency

Tools

Microsoft Office

Google Suite

Job description

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.

Successin 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.
• 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.

#LI-REMOTE

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

Voluntary Self-Identification

For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.

As set forth in Clover Health’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service‑connected disability.

A "recently separated veteran" means any veteran during the three‑year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Select...

We use AI-powered tools to compare your application against our job requirements.