Inpatient Coder Senior Associate

The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Tech teams. The Payment Integrity team ensures that Clover pays claims in an accurate manner, with a particular focus on reducing inappropriate medical spend.

As a Senior Associate - Inpatient Coder for Payment Integrity at Clover Health, you will play a key role ensuring that Clover is able to continue to build and scale a compliant, efficient and profitable program. You will work to ensure quality assurance standards and regulatory policy are reflected in claims processing practices. You will help drive value for every member by ensuring that Clover’s medical claims are paid accurately and recovering overpayments when they are identified. The Senior Associate - Inpatient Coder monitors and coordinates the identification of provider DRG denials and upcoding.

As an Inpatient Coder Senior Associate, you will:

• Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on a prospective and retrospective basis that drive inaccurate payments to providers.
• Proactively identify overpayments to ensure accurate claims payments on all inpatient services.
• Prepare response letters to deliver our decisions to members and/or providers within the regulatory timeframes set forth by the Centers for Medicare & Medicaid Services (CMS).
• Act as a subject-matter expert for cross-functional clinical reviews: digest complex concepts and regulations and communicate them effectively to different stakeholders, including senior-level leadership.
• Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
• Work closely with data scientists, engineers and operational teams to create sustainable and scalable solutions.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.
• Identify and review potential program efficiencies and opportunities.
• Continue to analyze existing policies to ensure accuracy and proper execution.
• Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.
  

Success in this role looks like:

• By the end of your initial 90-day period, you will have demonstrated a strong understanding of clinical coding practices and medical records review, while assisting our team in areas of DRG validation, avoidable readmission reviews, and clinical appeal reviews.
• By 6 months, you will be working autonomously to execute within our clinical review workflows and will have developed strong interpersonal relationships across the organization, becoming a trusted subject matter expert.
• Continued success in this position anchors in on developing a deep understanding of the workflows that support our clinical review life cycle, while maintaining regulatory compliance standards.
  

You should get in touch if:

• You hold a CCS certification or similar inpatient coding certification; required.
• You have a deep knowledge and understanding of DRG pricing methodology; required.
• You have current or previous nursing or firsthand clinical experience; preferred.
• You have 5+ years of experience in inpatient clinical coding; preferred.
• You have Medicare or Medicare Advantage payment integrity or claims operations experience; preferred
• You are technologically savvy with strong computer skills in Excel and PowerPoint.
• You have knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus.
  

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture th