Remote DRG Validation Auditor for Inpatient Claims

Clover Health; United States; Remote; USD 76,000 - 99,000; Full time

Benefits offered by this job

Competitive base salary

Performance-based bonus program

401k matching

Medical, dental, vision coverage

Remote-first culture

Job summary

Clover Health is seeking a DRG Validation Auditor to ensure accurate inpatient claims payments and to recover overpayments. You will collaborate with Clinical, Claims, and Payment Integrity teams to validate DRGs, review medical records, and engage MDs on clinical justification.

The role emphasizes regulatory compliance, cross-team communication, and continuous improvement of the clinical review lifecycle in a remote-first environment.

Qualifications

• You should hold a CCS or CIC certification and have DRG coding knowledge.
• You have at least 1 year of direct inpatient clinical coding experience.
• Experience with Medicare or Medicare Advantage payment integrity or claims operations is preferred.
• You are tech-savvy with strong Excel and PowerPoint skills.

Responsibilities

• Partner with Clinical, Claims, and Payment Integrity teams to review claims for DRG issues on a prospective and retrospective basis.
• Proactively identify overpayments to ensure accurate inpatient claims payments.
• Participate in discussions with MDs to verify clinical rationale behind billed procedures.
• Communicate effectively to build trust across cross-functional teams and ensure proper provider notification.
• Support regulatory compliance standards in claims processing and DRG validation workflows.

Skills

CCS/CIC certification

DRG pricing knowledge

Inpatient coding experience

Medicare/Medicare Advantage experience

Excel & PowerPoint proficiency

Tools

Excel

PowerPoint

Job description

Clover Health is seeking a DRG Validation Auditor to ensure accurate inpatient claims payments and to recover overpayments. You will collaborate with Clinical, Claims, and Payment Integrity teams to validate DRGs, review medical records, and engage MDs on clinical justification.

The role emphasizes regulatory compliance, cross-team communication, and continuous improvement of the clinical review lifecycle in a remote-first environment.