Associate, Medical Claims Auditor

2 weeks ago

Jersey City, United States Clover Health Full time

Clover is reinventing health insurance by working to keep people healthier._

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). Come join us as we discover new opportunities to enhance the fight against 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.

**As an Associate, Medical Claims Auditor, you will**:

- 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.

**You will love this job if**:

- You want to make an **impact**. You thrive off of helping others, and want your work to make a difference in our members' lives.
- You are a critical** thinker**, passionate about researching regulations and billing guidelines to ensure accurate claims payments.
- You are a **team player**. You enjoy partnering with others, and want to work collaboratively to find new solutions.
- You are a **strong communicator**. You have strong verbal and written communication skills that foster trust, knowledge sharing, and progress.
- You are **detail-oriented**. You pay attention to the small things, while understanding how they fit into the bigger picture.
- You are **motivated to learn**. There is no shortage of technical, clinical, and operational skills to learn at Clover.
- You are **curious**. You like to do research when you don't know an answer. You ask the hard questions and you don't sweep problems under the rug.

**You should get in touch if**:

- You have 2+ years of coding and auditing experience, experience with CMS regulations preferred.
- Certified Professional Coder (CPC) or other coding certification is a plus.
- You have a strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI.
- You have experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite.
- You have prior experience working in health insurance; Medicare Advantage is a plus.
- #LI-Remote_
- Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. _We are an _E-Verify_ company._

**Colorado/Washington Pay Range**

$72,000 - $99,000 USD

**California/New Jersey/New York Pay Range**

$72,000 - $110,000 USD

**About Clover**:We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover's inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one's identity. All of our employee's points of view are key to our success, and inclusion is everyone's responsibility.

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