Medical Claims Auditor
About the position
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.
Responsibilities
• 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.
Requirements
• You have 3+ years of coding and auditing experience, experience with CMS regulations preferred.
• 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.
Nice-to-haves
• You have a Certified Professional Coder (CPC) or other coding certification is a plus.
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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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.
Responsibilities
• 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.
Requirements
• You have 3+ years of coding and auditing experience, experience with CMS regulations preferred.
• 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.
Nice-to-haves
• You have a Certified Professional Coder (CPC) or other coding certification is a plus.
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
Apply tot his job
Apply To this Job
Apply tot his job
Apply To this Job