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Senior Claims Researcher

1 week ago
United States
Full-time
Senior
Operations Analyst
Operations
JIRA LLM Machine Learning
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 42

Description

  • Execute the monthly technical audit plan for claims payment accuracy.
  • Review claims against provider contracts, benefit rules, and pricing guidelines.
  • Perform root-cause research in HealthEdge HRP and Source to identify configuration issues, manual intervention, or policy misinterpretation.
  • Compile audit findings, categorize errors, and present trend analysis for leadership reporting.
  • Support AI and machine learning auditing tools by providing human-in-the-loop feedback to refine automated models.
  • Partner with BPaaS stakeholders and internal configuration teams to communicate findings and drive systemic resolution.
  • Track audit issues in JIRA from identification through resolution.
  • Serve as a final safeguard to ensure adjudication outputs match contractual and benefit intent.
  • Perform random and risk-based judgmental audits to support baseline payment accuracy.
  • Develop ongoing monitoring and oversight trends to identify high-impact risks and support targeted audits.

Requirements

  • 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication.
  • Current coding certification required: CPC, CCS, COC, or CIC.
  • Deep technical proficiency in HealthEdge HRP and Source.
  • Strong ability to analyze complex data and determine root cause in technical problems.
  • Experience using AI tools and LLMs such as Claude, Gemini, and ChatGPT for auditing or research.
  • Strong communication skills for translating technical findings into clear, actionable reports for leadership.
  • Experience in claims auditing or complex adjudication is required; Medicare Advantage experience preferred.
  • Comfort working in a remote-first environment.
  • Salary range of $107,000 to $130,000 USD, based on experience, certifications, and other factors.

Benefits

  • Competitive base salary with equity opportunities.
  • Performance-based bonus program.
  • 401(k) matching.
  • Comprehensive medical, dental, and vision coverage.
  • Generous flexible time-off policy.
  • Remote-first culture with flexibility to work from any location.
  • Mental health resources, No-Meeting Fridays, and monthly company holidays.
  • Learning programs, mentorship, professional development funding, and regular performance feedback.
  • Employee Stock Purchase Plan (ESPP) with discounted equity opportunities.
  • Reimbursement for office setup expenses.
  • 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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