Payment Integrity Analyst

Job not on LinkedIn

🔥 1 minute ago

🇺🇸 United States – Remote

💵 $76.9k - $100k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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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

• Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge • Review claims populations identified through SQL analysis and distinguish payment discrepancies from valid exceptions, data issues, and correctly adjudicated claims • Research CMS/NCCI and other coding guidance, provider contract terms, benefit documents, 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 • Independently run SQL queries and adapt dates, filters, and claim selections • Seek evidence that could disprove suspected issues, including correctly paid comparison claims and alternative explanations • Document sources, validation steps, exclusions, payment impact, and unresolved questions for reproducible review • Use approved AI tools for research, query interpretation, and documentation while verifying outputs • Review and audit audit-tool outputs, identify false positives, and refine rules • Prepare findings for review and support recovery evaluation, operational resolution, and Compliance/Legal review • Contribute to recurring audits, monitor validated issues, and recommend improvements to investigation and testing processes

🎯 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 • Knowledge of benefit provisions, provider contracts, payment policies, and configuration impacts on payment outcomes • Ability to investigate payment discrepancies, test competing explanations, recognize exceptions, and distinguish suspected issues from supported findings • Ability to independently conduct defined investigations, identify missing information, and escalate complex or unresolved questions • Practical SQL proficiency and ability to navigate large relational database environments • Strong Excel skills and experience reviewing, filtering, comparing, and reconciling claims-level datasets • Hands-on experience using AI tools in analytical, research, or claims-related work, with sound judgment regarding verification and data handling • Clear written and verbal communication skills • Strong attention to detail and ability to manage multiple investigations with organized, traceable documentation • Experience with Medicare Advantage claims and reimbursement • Coding or reimbursement credentials are advantageous but not required

🏖️ 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