Medical Claims Auditor

Clover Health

1d•Remote

About The Position

The Special Investigation Unit (SIU) is a motivated, collaborative team sitting at the intersection of Compliance, Payment Integrity, and Data Infrastructure. The SIU ensures that Clover monitors, identifies, and investigates instances of healthcare fraud, waste and abuse (FWA). As a Medical Claims Auditor within our Special Investigations Unit, you will play a critical role in ensuring that Clover is able to continue to build and scale a compliant, effective FWA audit program. You will be joining a fast-growing and fast-moving startup at the intersection of healthcare and technology, where you will have the opportunity to develop both your policy and operational skills. A successful Medical Claims Auditor 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.

Requirements

3+ years of coding and auditing experience
Experience with CMS regulations preferred.
Strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI.
Experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite.
Prior experience working in health insurance; Medicare Advantage is a plus.

Nice To Haves

Certified Professional Coder (CPC) or other coding certification is a plus.

Responsibilities

Partner with Clinical, Claims, and SIU peers to review claims for billing and coding related issues on a retrospective basis that currently drive inaccurate payments to providers or indicate FWA.
Identify control opportunities to mitigate FWA.
Identify possible audit opportunities.
Support annual FWA audit goals.
Support provider conversations around FWA audit findings.
Manage overall audit workload to ensure timely and accurate audit results.
Work closely with senior team members and management on targeted projects and initiatives.
Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.