Senior Clinical Payment Integrity Auditor

1 hour, 41 minutes ago
Full-time
Senior
Operations
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

Description

  • Lead prospective claim review audits for clinical DRG coding compliance, readmissions programs, and high-dollar claim reviews.
  • Ensure payment integrity programs run smoothly and remain compliant with internal policies and Medicare guidelines.
  • Prepare provider responses that clearly communicate review decisions within CMS regulatory timeframes.
  • Identify program efficiencies and implement procedural improvements.
  • Analyze existing policies to ensure accuracy and proper execution.
  • Collaborate cross-functionally to support provider understanding of payment integrity recommendations and defend those recommendations when needed.
  • Serve as a subject matter expert on clinical coding guidelines and communicate complex rules to stakeholders, including senior leadership.
  • Train team members, help prioritize work, and support development of additional responsibilities.
  • Research and respond to external auditor questions about data creation, completeness, and integration.
  • Support accurate claims adjudication and proper provider notification through effective internal and external communication.

Requirements

  • CCS or CIC certification is required.
  • Current or previous nursing experience, firsthand clinical experience, or CDI certification is required.
  • Previous experience in the insurance industry.
  • Deep understanding of CMS rules and regulations.
  • Strong computer skills with Access, Excel, Visio, and PowerPoint.
  • Knowledge of statistical methods used to evaluate healthcare claims data is preferred.
  • SQL knowledge is a plus.
  • Ability to work with evolving priorities and ad hoc requests.
  • Experience explaining complex clinical coding concepts to different stakeholders, including leadership.

Benefits

  • Competitive base salary of $92,000 to $120,000 USD.
  • Equity opportunities, including an Employee Stock Purchase Plan (ESPP).
  • Performance-based bonus program and 401(k) matching.
  • Comprehensive medical, dental, and vision coverage.
  • Remote-first culture with flexibility to work from any location.
  • No-Meeting Fridays, monthly company holidays, and a generous flexible time-off policy.
  • Access to mental health resources.
  • Learning programs, mentorship, professional development funding, and regular performance feedback.
  • Paid parental leave for all new parents.
  • Monthly cell phone and internet stipend, plus office setup reimbursement.

Interested in this position?

Apply directly on the company website

Apply Now

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