Medical Claims Auditor
About The Position
The Medical Claims Auditor joins Clover’s Special Investigation Unit (SIU), a collaborative team working across Compliance, Payment Integrity, and Data Infrastructure to monitor, identify, and investigate healthcare fraud, waste, and abuse (FWA). This role helps build and scale a compliant and effective FWA audit program, with a focus on Medicare coding policies and broad coding expertise, including DME, outpatient, ASC, and physician correct coding. The auditor reviews claims for billing and coding issues on prepayment and retrospective bases, uses internal AI tools and predictive models to find anomalous billing patterns and targeted audit opportunities, and provides coding feedback to improve machine-learning models. The role also identifies systemic controls and prepayment edits, supports high-value reviews and provider communications, and manages audit work to meet strict prepayment turnaround times. Success involves learning Clover’s review processes and systems during the first 90 days, working autonomously on provider reviews and supporting case identification by six months, and developing deep knowledge of SIU workflows while maintaining regulatory compliance.
Requirements
- At least 3 years of coding and auditing experience.
- Certified Professional Coder (CPC) credential.
- Strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI.
- Experience with technology environments, including claims systems, workflow management tools, and Microsoft Office or Google Suite.
Nice To Haves
- Experience with CMS regulations.
- Prior experience working in health insurance.
- Medicare Advantage experience.
Responsibilities
- Partner with Clinical, Claims, and SIU peers to review claims for billing and coding issues on prepayment and retrospective bases.
- Use internal AI tools and predictive models to identify anomalous billing patterns, emerging trends, and opportunities for targeted prepayment audits.
- Collaborate with Data Science and Engineering to validate AI-flagged claims and provide coding feedback to train and refine machine-learning models.
- Identify opportunities to mitigate FWA, with a focus on implementing systemic prepayment edits.
- Identify audit opportunities using AI-assisted data analysis and manual case identification.
- Support annual FWA audit goals by prioritizing high-value reviews.
- Support provider conversations about FWA audit findings by translating data, AI insights, and prepayment denials into actionable compliance feedback.
- Manage audit workload to deliver timely and accurate results within prepayment turnaround times.
- Work with senior team members and management on targeted projects and initiatives.
- Build effective partnerships and communicate across multidisciplinary teams.
Benefits
- Competitive base salary and equity opportunities.
- Performance-based bonus program.
- 401(k) matching.
- Regular compensation reviews.
- Medical, dental, and vision coverage.
- No-Meeting Fridays.
- Monthly company holidays.
- Mental health resources.
- Generous flexible time-off policy.
- Remote-first culture.
- Learning programs and mentorship.
- Professional development funding.
- Regular performance feedback and reviews.
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
