Senior Auditor, Clinical Coding Review
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 spend. As a Senior Auditor 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 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.
Nice To Haves
- Knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus.
Responsibilities
- Lead prospective claim review audits related to clinical DRG coding compliance and readmissions programs as well as cross-functional high dollar claim review.
- 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
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
251-500 employees
