Clover Health - Medical Claims Auditor

• 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. • 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. • You should get in touch if: • 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.