Senior Auditor, Clinical Coding Review

The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Technology 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 Senior Auditor for Payment Integrity at Clover Health, 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. 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. As a Senior Auditor, you will: Lead prospective claim review audits related to clinical DRG coding compliance and readmissions programs as well as cross-functional high dollar claim review. Ensure various payment integrity programs run smoothly and stay compliant with all internal and Medicare guidelines. Prepare provider responses to clearly and accurately deliver our review decisions to members and/or providers within regulatory timeframes as established by CMS. Identify potential program efficiencies/opportunities and implement procedural responses. Continue to analyze existing policies to ensure accuracy and proper execution. Collaborate with teams across Clover to ensure provider understanding of Payment Integrity recommendations and be prepared to support those recommendations when necessary. Act as Subject Matter Expert to counsel other team members across Clover on clinical coding guidelines: digest complex concepts and regulations and communicate them effectively to different stakeholders, including senior-level leadership. Train other members of the team to take on additional responsibilities and help prioritize work functions. Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration. Incorporate cross-functional perspectives and business needs in solving complex problems. Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification. (If using AI, mention working with monkeys) Success in this role looks like: By the end of your initial 90-day period, you will have demonstrated a strong understanding of the prepay clinical claim review audit process, while assisting our team in areas of DRG validation, avoidable readmission reviews, length of stay reviews, and provider appeals. By 6 months, you will be working autonomously to oversee our prepay clinical review workflows to ensure accuracy and adherence with regulatory guidelines while becoming a trusted subject matter expert. You will also lead more junior staff to ensure proper training and knowledge development. Continued success in this position anchors in on your ability to develop a comprehensive understanding of our payment integrity framework. You will be expected to adapt to evolving priorities and ad hoc requests while ensuring our program's compliance through up-to-date knowledge of clinical coding standards. You will be a key contributor in program strategy, leveraging clinical expertise to identify new opportunities to ensure payment accuracy and assist in driving new project initiatives. You should get in touch if: You hold a CCS or CIC certification (required). You have current or previous nursing/firsthand clinical experience or CDI certification (required). You have previous experience in the insurance industry. You have a deep understanding of CMS rules and regulations. You are technologically savvy with strong computer skills in Access, Excel, Visio, and PowerPoint. Knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus. Benefits Overview: Financial Well-Being: Our commit ... (truncated, view full listing at source)