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Payment Integrity Analyst

16 hours, 51 minutes ago
United States
Full-time
Mid Level
Financial Analyst
Data Science and Analytics
SQL
Apply Now
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised
View All Jobs 28

Description

  • Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge.
  • Review SQL-identified claims populations and distinguish supported discrepancies from valid exceptions, data issues, and correctly adjudicated claims.
  • Research CMS, NCCI, coding guidance, provider contracts, benefit documents, payment policies, and configuration requirements.
  • Analyze claim details, payment components, adjustments, reversals, and related claim history to determine expected outcomes.
  • Run and adapt existing SQL queries by modifying dates, filters, and claim selections.
  • Test alternative explanations and seek evidence that could disprove suspected payment issues.
  • Document sources, validation steps, exclusions, payment impacts, and unresolved questions for reproducible review.
  • Use approved AI tools for research, query interpretation, and documentation while verifying outputs and sources.
  • Audit tool outputs, identify false positives, and refine rules to improve precision.
  • Prepare findings for recovery evaluation, operational resolution, and Compliance or Legal review.
  • Contribute to recurring audits and improve investigation, testing, and documentation processes.

Requirements

  • 3–5 years of experience in payment integrity, reimbursement analysis, claims audit, claims research, claims examination, or related work, including direct Medicare Advantage experience.
  • Strong practical knowledge of Medicare Advantage claims adjudication and reimbursement.
  • Understanding of how benefits, provider contracts, payment policies, and configuration affect claim outcomes.
  • Ability to investigate discrepancies, test competing explanations, recognize exceptions, and validate findings.
  • Ability to independently manage investigations, identify missing information, and escalate unresolved questions clearly.
  • Practical SQL proficiency and experience navigating large relational databases.
  • Strong Excel skills for reviewing, filtering, comparing, and reconciling claims datasets.
  • Hands-on experience using AI tools in analytical, research, or claims-related work with appropriate verification and data handling.
  • Clear written and verbal communication skills for explaining complex findings to technical and operational partners.
  • Strong attention to detail and ability to manage multiple investigations with organized documentation.
  • Experience with overpayment investigations, payment corrections, recovery review, claims payment rules, configuration discrepancies, or recurring audits preferred.
  • Relevant coding or reimbursement credentials preferred but not required.

Benefits

  • Base salary range of $76,900–$100,000 USD, plus equity opportunities.
  • Performance-based bonus, 401(k) matching, compensation reviews, and an employee stock purchase plan.
  • Medical, dental, and vision coverage.
  • Remote-first work culture, flexible time off, monthly company holidays, and No-Meeting Fridays.
  • Mental health resources and wellness support.
  • Learning programs, mentorship, professional development funding, and performance feedback.
  • Office setup reimbursement and monthly cell phone and internet stipend.
  • Paid parental leave for all new parents.

Interested in this position?

Apply directly on the company website

Apply Now

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