Medicare Payment Integrity Analyst — Remote

Clover Health; United States; Remote; USD 77,000 - 100,000; Full time

Benefits offered by this job

Equity opportunities

ESPP

Remote-first culture

No-Meeting Fridays

Parental leave

Cell phone stipend

Job summary

Clover Health is seeking a Payment Integrity Analyst to investigate Medicare Advantage payment accuracy, review SQL-identified populations, and translate findings into actionable recommendations. You’ll document validation steps and collaborate with a Senior Manager on validation methodology, using AI tools thoughtfully.

The role requires strong Medicare Advantage knowledge, SQL proficiency, and experience with data-driven audits, while offering a remote-first environment and opportunities for

Qualifications

• 3–5 years of relevant experience in payment integrity, reimbursement analysis, claims audit or related work, including Medicare Advantage experience.
• Strong practical knowledge of Medicare Advantage claims adjudication and reimbursement.
• Practical SQL proficiency and ability to navigate large relational databases.
• Strong Excel skills for reviewing and reconciling claims-level datasets.
• Hands-on experience using AI tools in analytical work and sound judgment on data handling.

Responsibilities

• Investigate potential payment inaccuracies using Medicare Advantage knowledge to interpret claims data.
• Review claims populations identified through SQL analysis and distinguish discrepancies from valid exceptions.
• Research CMS/NCCI guidance, provider contracts, and internal payment policies to determine applicability and dates.
• Analyze claim detail, payment components, adjustments, and history to assess outcomes.
• Independently run SQL queries and adapt date filters and selections as needed.
• Seek evidence to disprove suspected issues, including correctly paid comparison claims and alternative explanations.
• Document sources, validation steps, exclusions, and unresolved questions clearly for reproducibility.
• Use approved AI tools to support research, while verifying sources and analytic outputs.
• Review and audit outputs from audit tools to refine rules and improve precision.
• Prepare findings for review and downstream recovery evaluation.

Skills

SQL analysis

Medicare Advantage knowledge

Claims auditing

Data interpretation

Investigation

Excel

AI tools usage

Documentation

Communication

Tools

SQL

Audit tools

Excel

AI tools

Job description

Clover Health is seeking a Payment Integrity Analyst to investigate Medicare Advantage payment accuracy, review SQL-identified populations, and translate findings into actionable recommendations. You’ll document validation steps and collaborate with a Senior Manager on validation methodology, using AI tools thoughtfully.

The role requires strong Medicare Advantage knowledge, SQL proficiency, and experience with data-driven audits, while offering a remote-first environment and opportunities for