Payment Integrity Analyst

Clover Health

9h • $90,000 - $120,000 • Remote

About The Position

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 spending.
As a Payment Integrity Analyst, you will be responsible for identifying, researching, developing, and maintaining a portfolio of medical cost savings opportunities. This position will leverage strong technical knowledge to build complex SQL queries to size and ultimately deploy high-value individual cost-savings concepts as well as assist with the identification of these audit opportunities. In addition, the Senior Associate will be responsible for the creation of monthly, quarterly, and annual Payment Integrity financial reports as well as ad-hoc reports to support operations.

Requirements

• You have experience working with complex processes in a technical environment and synthesizing data for senior leadership.
• You have 2+ years of experience with expert-level SQL proficiency and a deep background in healthcare claims analysis.
• You are expert at leveraging AI-assisted workflows to accelerate complex query writing and data cleaning. Highly skilled in translating claims data into actionable insights using Excel, Visio/Lucid, and Google Suite.
• You hold a BA/BS degree or equivalent experience along with 5+ years of experience in the data and analytics space.
• You have 2+ years of experience working in healthcare data, preferably Medicare related.
• You have experience with GitHub (branching, merging, pull requests) and move-to-production protocols.
• You have a working knowledge of CMS rules and regulations.

Responsibilities

• Identify, develop, and deploy a portfolio of cost-saving concepts and initiatives that drive specific and measurable results for Clover.
• Translate individual concepts into SQL code that can be deployed in an automated fashion against Clover's pending and/or paid claims data.
• Support existing and develop new medical record review and administrative hold concepts/edits to drive specific and measurable results.
• Lead cross-functional discussions with billing experts, clinical staff, and operations managers to translate complex claims data into operational improvements.
• Train other members of the team to create SQL code for minor reporting or quick analysis.
• Support the team with daily operational tasks such as triaging Salesforce tickets, assisting with audit letter creation, and reimbursement processing.
• Influence senior leadership to adopt new policies, procedures, concepts, and initiatives to drive claims payment accuracy and medical cost containment.
• Act as a subject matter expert on all things data-related, including claims, enrollment, and clinical. Partner with data and engineering teams to investigate data issues when they intersect with payment integrity processes.
• Generate monthly, quarterly, and annual payment integrity financial reports as well as ad-hoc reports to support operational functions.

Benefits

• 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 that supports collaboration and flexibility, allowing our team members to thrive from any location.
• Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for all new parents

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level