[Hiring] DRG Inpatient Coding Validator @Clover Health

Role Description

The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Tech teams. The Payment Integrity team ensures that Clover pays claims in an accurate manner, with a particular focus on reducing inappropriate medical spend.

As a DRG Inpatient Coding Validator at Clover Health, you will play a key role ensuring that Clover is able to continue to build and scale a compliant, efficient and profitable program. You will work to ensure quality assurance standards and regulatory policy are reflected in claims processing practices. You will help drive value for every member by ensuring that Clover’s medical claims are paid accurately and recovering overpayments when they are identified. The Associate - Inpatient Coder coordinates the identification of provider DRG denials and upcoding.

As a DRG Inpatient Coding Validator, you will:

• Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on a prospective and retrospective basis that drive inaccurate payments to providers.
• Proactively identify overpayments to ensure accurate claims payments on inpatient services.
• Participate in collaborative discussions with MDs to verify the clinical rationale behind billed procedures.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.
• Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.

Success in this role looks like:

• By the end of your initial 90-day period, you will have demonstrated a strong understanding of clinical coding practices and medical records review, while assisting our team in areas of DRG validation.
• By 6 months, you will be working autonomously to execute within our clinical review workflows and will have developed strong interpersonal relationships across the organization.
• Continued success in this position anchors in on developing a deep understanding of the workflows that support our clinical review life cycle, while maintaining regulatory compliance standards.

Qualifications

• You hold a CCS or CIC certification; required.
• Knowledge of DRG pricing methodology; required.
• You have at least 1 year of direct inpatient clinical coding experience.
• Medicare or Medicare Advantage payment integrity or claims operations experience; preferred.
• You are technologically savvy with strong computer skills in Excel and PowerPoint.

Benefits

• Financial Well-Being: Competitive base salary and equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and vision coverage.
• Mental Well-Being: Initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.
• Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Additional Perks: Employee Stock Purchase Plan (ESPP), reimbursement for office setup expenses, monthly cell phone & internet stipend, remote-first culture, paid parental leave for all new parents, and much more!