Senior Clinical Payment Integrity Auditor

Cloverhealth

Remote
Base: $92,000 - $120,000; bonus/equity: performanc...
Remote
Clinical drg coding compliance
Reduce inappropriate medical spend
Medicare guidelines
Clover Health is seeking a Senior Clinical Payment Integrity Auditor to enhance its payment accuracy and compliance within the clinical claims processing framework. The ideal candidate will have a strong background in clinical coding, a CCS or CIC certification, and experience in the insurance industry

Job Summary

  • The Payment Integrity team ensures that Clover pays claims in an accurate manner, with a particular focus on reducing inappropriate medical spend.
  • You will ensure the health of our prepay clinical review program by playing a key role in program development and expansion, cross-functional cooperation, and ensuring quality assurance standards and regulatory policy are reflected in clinical claims processing practices.
  • We offer comprehensive medical, dental, and vision coverage, No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.

Matching Summary

Match Score: 85

Clover Health is seeking a Senior Clinical Payment Integrity Auditor to enhance its payment accuracy and compliance within the clinical claims processing framework. The ideal candidate will have a strong background in clinical coding, a CCS or CIC certification, and experience in the insurance industry.

Salary

Base: $92,000 - $120,000; Bonus/Equity: performance-based bonus program, equity opportunities; Benefits: comprehensive medical, dental, and vision coverage, 401k matching

Skills & Requirements

Must-have

  • clinical DRG coding compliance
  • reduce inappropriate medical spend
  • Medicare guidelines
  • provider responses
  • cross-functional collaboration

Nice-to-have

  • innovative thinkers
  • drive value for every member
  • solving complex problems
  • adapt to evolving priorities

Key Requirements

  • CCS or CIC certification
  • current or previous nursing/firsthand clinical experience or CDI certification
  • previous experience in the insurance industry
  • deep understanding of CMS rules and regulations
  • strong computer skills in Access, Excel, Visio, and PowerPoint

Work Rights

Not specified

Tailored Resume

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