Clinical Coding Manager

Clover Health

85d • $100,000 - $130,000

About The Position

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 Technology 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 Clinical Coding Manager for Payment Integrity at Clover Health, you will ensure the health of our prepay clinical review program by playing a key role in program development and expansion, cross-functional cooperation, and ensuring quality assurance standards and regulatory policy are reflected in clinical 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.

Requirements

• You hold a CCS or CIC certification (required).
• You have current or previous nursing/firsthand clinical experience or CDI certification (required).
• You have at least 5+ years of experience in Medicare or Medicare Advantage payment integrity or claims operations experience.
• You have previous experience in the insurance industry.
• You have a deep understanding of CMS rules and regulations.
• You are technologically savvy with strong computer skills in Access, Excel, Visio, and PowerPoint. Knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus.

Responsibilities

• Manage prospective claim review queues related to clinical DRG coding compliance and readmissions programs as well as cross-functional high dollar claim review.
• Develop and execute strategies and procedures to contribute to the growth of the payment integrity team and drive process improvements.
• Ensure various payment integrity programs run smoothly and stay compliant with all internal and Medicare guidelines.
• Prepare provider responses to clearly and accurately deliver our review decisions to members and/or providers within regulatory timeframes as established by CMS.
• Identify potential program efficiencies/opportunities and implement procedural responses.
• Continue to analyze existing policies to ensure accuracy and proper execution.
• Collaborate with teams across Clover to ensure provider understanding of Payment Integrity recommendations and be prepared to support those recommendations when necessary.
• Act as Subject Matter Expert to counsel other team members across Clover on clinical coding guidelines: digest complex concepts and regulations and communicate them effectively to different stakeholders, including senior-level leadership.
• Train other members of the team to take on additional responsibilities and help prioritize work functions.
• Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
• Incorporate cross-functional perspectives and business needs in solving complex problems.
• Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.

Benefits

• Competitive base salary and equity opportunities.
• Performance-based bonus program.
• 401k matching.
• Regular compensation reviews.
• Comprehensive medical, dental, and vision coverage.
• No-Meeting Fridays.
• Monthly company holidays.
• Access to mental health resources.
• Generous flexible time-off policy.
• Remote-first culture.
• Learning programs and mentorship.
• Professional development funding.
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.
• Reimbursement for office setup expenses.
• Monthly cell phone & internet stipend.
• Paid parental leave for all new parents.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees