Payment Integrity Analyst

Clover Health

1d•$76,900 - $100,000•Remote

About The Position

Clover Health is seeking a Payment Integrity Analyst to join their Payment Integrity team. This role is responsible for ensuring claims are paid accurately, consistently, and in accordance with applicable requirements. The analyst will investigate potential payment inaccuracies, evaluate claims populations identified through SQL analysis, and determine whether the evidence supports a payment issue or a correctly adjudicated outcome. This involves researching applicable requirements, working through claim histories and exceptions, and translating validated findings into actionable recommendations and repeatable audits. The analyst will work closely with the Senior Manager on SQL development, investigation priorities, and validation methodology. The role requires comfort with running and adapting existing queries, thoughtful use of AI tools, and ownership of investigations from review to documented recommendation.

Requirements

3–5 years of relevant experience in payment integrity, reimbursement analysis, claims audit, complex claims research, claims examination, or related work, including direct Medicare Advantage experience.
Strong practical knowledge of Medicare Advantage claims adjudication and reimbursement, including how benefit provisions, provider contracts, payment policies, and configuration can affect outcomes.
Ability to investigate payment discrepancies, test competing explanations, recognize exceptions, and distinguish a suspected issue from a supported finding.
Ability to independently work through defined investigations, identify missing information, and escalate complex or unresolved questions with a clear explanation of the evidence needed.
Practical SQL proficiency and ability to navigate large relational database environments, recognizing unexpected duplication, exclusions, or changes in results.
Strong Excel skills and experience reviewing, filtering, comparing, and reconciling claims-level datasets.
Meaningful hands-on experience using AI tools in analytical, research, or claims-related work and exercise sound judgment about verification and appropriate data handling.
Clear written and verbal communication skills, with the ability to explain complex findings to technical and operational partners.
Strong attention to detail and ability to manage multiple investigations while maintaining organized, traceable documentation.

Nice To Haves

Supported overpayment investigations, payment corrections, or recovery review.
Tested claims payment rules or investigated configuration-related discrepancies.
Developed or maintained recurring claims audits.
Hold coding or reimbursement credentials relevant to your experience, though certification is not required.

Responsibilities

Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge to interpret claims data and explain payment outcomes.
Review claims populations identified through SQL analysis and distinguish supported payment discrepancies from valid exceptions, data issues, and correctly adjudicated claims.
Research applicable CMS/NCCI and other coding guidance, provider contract terms, benefit documents, and internal payment policies and configuration requirements. Identify effective dates, applicability, and unresolved source conflicts.
Analyze claim and line detail, payment components, adjustments, reversals, and related claim history to understand what occurred and assess the expected payment outcome.
Independently run SQL queries and make targeted changes to dates, filters, and claim selections.
Actively seek evidence that could disprove a suspected issue, including correctly paid comparison claims, exceptions, and alternative explanations.
Document the applicable sources, validation steps, exclusions, supported payment impact, and unresolved questions clearly enough for another reviewer to reproduce the conclusion.
Use approved AI tools to support research, query interpretation, and documentation while verifying sources, factual claims, and analytical outputs.
Review and audit outputs from audit tools, identifying false positives and refining rules to improve precision.
Prepare findings for review and support downstream recovery evaluation, operational resolution, and Compliance/Legal review as needed.
Contribute to recurring audits, monitor previously validated issues, and recommend improvements to investigation and testing processes.