[Hiring] Medical Claims Auditor @Clover Health

Role Description

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).

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.

As a Medical Claims Auditor, you will:

• Partner with Clinical, Claims, and SIU peers to review claims for billing and coding-related issues on both a prepayment and retrospective basis to prevent inaccurate payments to providers and disrupt FWA before funds leave the door.
• Leverage internal AI tools and predictive models to proactively identify anomalous billing patterns, emerging trends, and new opportunities for targeted prepayment audits.
• Collaborate directly with our Data Science and Engineering teams to validate AI-flagged claims in the prepayment queue, providing expert coding feedback to continuously train and refine our machine learning models.
• Identify control opportunities to mitigate FWA, focusing heavily on implementing systemic prepayment edits.
• Identify possible audit opportunities through AI-assisted data analysis and manual case identification.
• Support annual FWA audit goals by prioritizing high-value reviews.
• Support provider conversations around FWA audit findings, translating complex data, AI insights, and prepayment denials into clear, actionable compliance feedback.
• Manage overall audit workload to ensure timely and accurate audit results within strict prepayment turnaround times.
• 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.

Success in this role looks like:

• By the end of your initial 90 day period, you will have demonstrated a strong understanding of our review process and are able to effectively navigate through the various Clover systems.
• By 6 months, you will be working autonomously on provider reviews and supporting further case/opportunity identification.
• Continued success in this position anchors in on developing a deep understanding of the workflows that support our SIU cases and reviews while maintaining regulatory compliance standards.

Qualifications

• You have 3+ years of coding and auditing experience, experience with CMS regulations preferred.
• You are a Certified Professional Coder (CPC).
• 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.

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!

Company Description

We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives.