[Hiring] Payment Integrity Analyst @Clover Health

Role Description

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations.

Clover’s Payment Integrity team is responsible for ensuring claims are paid accurately, consistently, and in accordance with applicable requirements. We’re looking for a Payment Integrity Analyst who brings strong Medicare Advantage claims and reimbursement knowledge, investigative judgment, and the ability to translate claims data into defensible findings.

In this role, you’ll:

• Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge to interpret claims data and explain payment outcomes.
• Review claims populations identified through SQL analysis and distinguish supported payment discrepancies from valid exceptions, data issues, and correctly adjudicated claims.
• Research applicable CMS/NCCI and other coding guidance, provider contract terms, benefit documents, and internal payment policies and configuration requirements.
• Analyze claim and line detail, payment components, adjustments, reversals, and related claim history to understand what occurred and assess the expected payment outcome.
• Independently run SQL queries and make targeted changes to dates, filters, and claim selections.
• Actively seek evidence that could disprove a suspected issue, including correctly paid comparison claims, exceptions, and alternative explanations.
• Document the applicable sources, validation steps, exclusions, supported payment impact, and unresolved questions clearly enough for another reviewer to reproduce the conclusion.
• Use approved AI tools to support research, query interpretation, and documentation while verifying sources, factual claims, and analytical outputs.
• Review and audit outputs from audit tools, identifying false positives and refining rules to improve precision.
• Prepare findings for review and support downstream recovery evaluation, operational resolution, and Compliance/Legal review as needed.
• Contribute to recurring audits, monitor previously validated issues, and recommend improvements to investigation and testing processes.

Success in this role looks like:

• Within the first 90 days: You’ve developed a working understanding of Clover’s claims data, payment integrity workflows, and validation approach.
• Within six months: You’re taking ownership of defined investigations with limited day-to-day direction.
• Over time: Your work helps the team identify and validate payment inaccuracies more efficiently.

Qualifications

• 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.
• Ability to investigate payment discrepancies, test competing explanations, and recognize exceptions.
• Practical SQL proficiency and ability to navigate large relational database environments.
• Strong Excel skills and experience reviewing, filtering, comparing, and reconciling claims-level datasets.
• Meaningful hands-on experience using AI tools in analytical, research, or claims-related work.
• Clear communication skills in writing and verbally.
• Strong attention to detail and ability to manage multiple investigations.

Requirements

• Supported overpayment investigations, payment corrections, or recovery review.
• Tested claims payment rules or investigated configuration-related discrepancies.
• Developed or maintained recurring claims audits.
• Coding or reimbursement credentials relevant to your experience (certification not required).

Benefits

• Competitive base salary and equity opportunities.
• Performance-based bonus program, 401k matching, and regular compensation reviews.
• Comprehensive medical, dental, and vision coverage.
• Initiatives for mental health support, including No-Meeting Fridays and flexible time-off policy.
• Learning programs, mentorship, and professional development funding.
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.
• Reimbursement for office setup expenses.
• Monthly cell phone & internet stipend.
• Paid parental leave for all new parents.
• Remote-first culture enabling collaboration with global teams.