Senior Claims Researcher

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $107k - $130k / year

⏰ Full Time

🟠 Senior

🧬 Research Scientist

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Clover Health (Nasdaq: CLOV) is a physician enablement company focused on seniors who have historically lacked access to affordable, high-quality healthcareWe aim to provide great care, in a sustainable way, by having a business model built around improving medical outcomes while lowering avoidable costs. We do this while taking a holistic approach to understanding the health needs and social risk factors of those under our care. This strategy is underpinned by our proprietary software platform, the Clover Assistant, which is designed to aggregate patient data from across the health ecosystem to support clinical decision-making by presenting physicians and other providers with real-time, personalized recommendations at the point of care.Making care more accessible is at the heart of our business, and we believe patients should have the freedom to choose their doctors. We offer affordable Medicare Advantage plans with extensive benefits, provide primary care physicians with the Clover Assistant, and also make comprehensive home-based care available via the Clover Home Care program.With our corporate headquarters in Nashville, Clover’s workforce is distributed around the U.S. and also includes a team of world-class technologists based in Hong Kong. We manage care for Medicare Advantage members in Alabama, Arizona, Georgia, Mississippi, New Jersey, Pennsylvania, South Carolina, Tennessee, and Texas.We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road.If you’re a passionate person and interested in changing healthcare for the better, then Clover Health may just be the place for you.

📋 Description

• Technical Quality Auditing: Execute the monthly audit plan as designed by the Director, performing detailed reviews of claims to ensure they align with provider contracts, benefit rules, and pricing guidelines. • Root Cause Research: Go beyond identifying errors; perform deep-dive research into HealthEdge HRP and Source to determine if a variance was caused by configuration logic, manual intervention, or policy misinterpretation. • Data-Driven Reporting: Compile and present audit findings that highlight trends and "enterprise risk" areas, categorizing errors to provide the Director with actionable insights for executive-level reporting. • AI-Enabled Oversight: Support the implementation of AI and Machine Learning auditing tools by providing the "human-in-the-loop" feedback necessary to train and refine automated accuracy models. • BPaaS & Configuration Collaboration: Partner closely with our external BPaaS stakeholders and internal Configuration teams to communicate audit findings, utilizing JIRA to track the lifecycle of an error from identification to systemic resolution. • Strategic Testing: Act as the final safeguard for Clover’s adjudication accuracy, ensuring that the system's "real-world" output matches the contractual and benefit intent.

🎯 Requirements

• 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication. • You are a certified expert; a current coding certification is required (CPC, CCS, COC, or CIC). • You possess deep technical proficiency in HealthEdge HRP and Source. • You have a "researcher's mindset"—you are naturally curious, detail-oriented, and persistent in finding the root cause of a technical problem. • You are extremely AI-forward and excited to use technology and LLMs (Claude, Gemini, ChatGPT) to move away from manual, spreadsheet-based auditing. • You are a strong communicator who can translate complex technical findings into clear, actionable reports for leadership.

🏖️ 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. • Additional Perks: 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 • And much more!