Clover Health - Senior Claims Researcher

• By the end of your initial 90-day period: You will have mastered the nuances of Clover’s HealthEdge HRP and Source environments and will be actively executing the monthly audit cycle, performing both random and risk-based judgmental audits to ensure baseline payment accuracy. • By the end of your initial 90-day period: • By 6 months: You will be recognized as the "SME of Record" for identifying systemic payment trends across pricing and benefits. You will also be actively leveraging AI tools like Claude, Gemini, and ChatGPT to build out ongoing monitoring and oversight trends that identify high-impact risks to support judgmental sampling and targeted audits. • Continued success: You will be at the forefront of "Audit 2.0," utilizing AI-forward strategies to increase the scope and speed of your research. Your work will directly contribute to Clover’s commitment to achieving top-tier payment precision and the reduction of billing friction for our members and provider partners. • Continued success: • You should get in touch if: • You have 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication. • You are a certified expert; a current coding certification is required (CPC, CCS, COC, or CIC). • You possess deep technical proficiency in HealthEdge HRP and Source. • You have a "researcher's mindset"—you are naturally curious, detail-oriented, and persistent in finding the root cause of a technical problem. • You are extremely AI-forward and excited to use technology and LLMs (Claude, Gemini, ChatGPT) to move away from manual, spreadsheet-based auditing. • Claude, Gemini, ChatGPT • You are a strong communicator who can translate complex technical findings into clear, actionable reports for leadership.