Medical Claims Auditor

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $92.3k - $120k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🏥 Healthcare

🛡️ Insurance

🤖 Artificial Intelligence

Healthcare • Insurance • Artificial Intelligence

Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.

📋 Description

• Review claims for billing and coding-related issues on a prepayment and retrospective basis • Partner with Clinical, Claims, and SIU peers to prevent inaccurate provider payments and disrupt fraud, waste and abuse • Use internal AI tools and predictive models to identify anomalous billing patterns, emerging trends, and targeted prepayment audits • Collaborate with Data Science and Engineering teams to validate AI-flagged claims and provide coding feedback to refine machine learning models • Identify control opportunities and implement systemic prepayment edits to mitigate fraud, waste and abuse • Identify audit opportunities through AI-assisted data analysis and manual case identification • Support annual FWA audit goals by prioritizing high-value reviews • Support provider conversations around FWA audit findings and translate complex data, AI insights, and prepayment denials into compliance feedback • Manage audit workload to deliver timely and accurate results within strict prepayment turnaround times • Work with senior team members and management on targeted projects and initiatives • Build partnerships across multidisciplinary teams • Navigate Clover systems, conduct provider reviews autonomously, and support case/opportunity identification

🎯 Requirements

• 3+ years of coding and auditing experience • Experience with CMS regulations preferred • Certified Professional Coder (CPC) • Strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI • Experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite • Prior experience working in health insurance • Medicare Advantage experience is a plus • Broad coding knowledge including DME, Outpatient, ASC and Physician correct coding • Knowledge of Medicare coding policies

🏖️ Benefits

• Competitive base salary • Equity opportunities • Performance-based bonus program • 401k matching • Regular compensation reviews • Comprehensive medical, dental, and vision coverage • No-Meeting Fridays • Monthly company holidays • Mental health resources • Generous flexible time-off policy • Remote-first culture • Learning programs • Mentorship • Professional development funding • Regular performance feedback and reviews • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Collaboration with global teams • Paid parental leave for all new parents