Overview

Ever wonder what it's like to be on the front lines, making a real difference in healthcare by ensuring fairness and integrity? At Clover Health, we're not just talking about it; we're actively building a future where healthcare is accessible and honest for everyone. Our Special Investigation Unit (SIU) is on the lookout for a sharp Medical Claims Auditor, someone ready to dive deep into data, uncover patterns, and protect both patients and providers from fraud, waste, and abuse. This isn't just a job; it's a mission to enhance trust and efficiency in healthcare.

Joining our motivated, collaborative SIU team means sitting at the fascinating intersection of Compliance, Payment Integrity, and Data Infrastructure. You'll play a truly critical role in helping us build and scale a compliant, highly effective FWA audit program. We're a fast-growing startup, blending healthcare and technology, offering a unique opportunity for you to develop both your policy and operational skills. This is a fully remote, worldwide opportunity, inviting talented individuals from anywhere to contribute to our important work.

Key Responsibilities

In this vital role, your day will involve a variety of key tasks to safeguard our systems:

Collaborate closely with Clinical, Claims, and SIU colleagues, meticulously reviewing claims for any billing and coding related issues. This work will cover both prepayment and retrospective analyses to prevent inaccurate payments.
Conduct thorough audits of medical records, ensuring proper documentation and adherence to coding guidelines, with a specific focus on Medicare coding policies.
Identify potential instances of fraud, waste, and abuse, meticulously gathering evidence and supporting documentation for investigations.
Assist in the development and refinement of audit protocols and FWA detection methodologies, continuously seeking new opportunities to enhance our fight against improper claims.
Interpret and apply complex coding policies, including those related to DME, Outpatient services, Ambulatory Surgical Centers (ASC), and Physician correct coding practices.
Prepare detailed audit reports and present findings to internal stakeholders, offering clear insights and actionable recommendations.
Contribute to educational initiatives for internal teams, sharing expertise on coding best practices and FWA prevention.

Requirements

We're looking for someone who is passionate about detail and making an impact. Here are the core qualifications we believe will set you up for success:

Extensive Coding Knowledge: You should possess a broad coding knowledge base, encompassing areas like DME, Outpatient, ASC, and Physician correct coding practices.
Medicare Policy Expertise: A strong, specialized understanding of Medicare coding policies is absolutely essential for this role.
Analytical Mindset: Proven ability to analyze complex claims data, identify discrepancies, and draw sound conclusions.
Attention to Detail: An unwavering commitment to accuracy and precision in all aspects of your work.
Communication Skills: Excellent written and verbal communication abilities to articulate findings clearly to diverse audiences.
Collaboration Savvy: A desire to work effectively within a multidisciplinary team environment.
Experience in Healthcare Audit/SIU: Prior experience in a medical claims auditing role or within a Special Investigations Unit is highly advantageous.

What You'll Gain

Joining Clover Health means more than just a job; it's an opportunity to grow and make a tangible impact:

Direct Impact: You'll be at the forefront of combating FWA, directly contributing to more efficient and honest healthcare systems.
Skill Development: Enhance both your policy and operational skills within a dynamic, technology-driven healthcare environment.
Growth Environment: Thrive in a fast-moving startup culture where innovation is encouraged and your contributions are valued.
Collaborative Culture: Work alongside brilliant minds in Compliance, Payment Integrity, and Data Infrastructure.
Flexibility: Enjoy the benefits of a fully remote role, offering work-life balance from anywhere in the world.