Senior Associate, Medical Claims Auditor

Clover is reinventing health insurance by working to keep people healthier.

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. Come join us as we discover new opportunities to improve the financial health of Clover while strengthening provider relationships and building a better healthcare system.

As a Senior Associate, Medical Claims Auditor within our Payment Integrity team, you will play a critical role in ensuring that Clover is able to continue to build and scale a compliant, efficient, and financially stable program. You will work to ensure quality assurance standards and regulatory policy are reflected in claims processing practices. A successful Senior Associate, Physician Coder will have a broad coding knowledge base, including but not limited to: DME, Outpatient, ASC and Physician correct coding. This position will focus specifically on Medicare coding policies.

As a Senior Associate - Medical Claims Auditor, you will:

• Partner with Clinical, Claims, and Payment Integrity peers to review claims for billing and coding related issues on a retrospective basis that currently drive inaccurate payments to providers.
• Ensure end-to-end effectiveness of overpayment recovery operations from identification through collection and provider disputes, taking ownership of key work streams and associated decision points.
• 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 - digest complex Medicare concepts and regulations and communicate them effectively to different stakeholders, including providers and internal operational partners
• Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
• Work closely with analysts and operational teams to identify new overpayment concepts and maintain accuracy of existing identification criteria.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.

You will love this job if:

• You want to make an impact. You thrive off of helping others, and want your work to make a difference in our members' lives.
• You are a critical thinker, passionate about researching complex regulations and billing guidelines to ensure accurate claims payments.
• You are a team player. You enjoy partnering with others, and want to work collaboratively to find new solutions.
• You are a strong communicator. You have strong verbal and written communication skills that foster trust, knowledge sharing, and progress.
• You are detail-oriented. You pay attention to the small things, while understanding how they fit into the bigger picture.
• You are motivated to learn. There is no shortage of technical, clinical, and operational skills to learn at Clover.
• You are curious. You like to do research when you don't know an answer. You ask the hard questions and you don't sweep problems under the rug.

You should get in touch if:

• You have 7+ years of Payment Integrity, auditing, or claims experience, experience with CMS regulations preferred.
• Certified Professional Coder (CPC) or other coding certification is a plus.
• You have a strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI.
• You have experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite.
• You have prior experience working in health insurance; Medicare Advantage is a plus.

 

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Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinica