Inpatient Coder Senior Associate, Payment Integrity

Clover is reinventing health insurance by working to keep people healthier.
The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Tech 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 Associate - Inpatient Coder for Payment Integrity at Clover Health, you will play a key role ensuring that Clover is able to continue to build and scale a compliant, efficient and profitable program. You will work to ensure quality assurance standards and regulatory policy are reflected in 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. The Senior Associate - Inpatient Coder monitors and coordinates the identification of provider DRG denials and upcoding.
As an Inpatient coder Senior Associate , you will:

• Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on a prospective and retrospective basis that drive inaccurate payments to providers.
• Proactively identify overpayments to ensure accurate claims payments on all inpatient services.
• Prepare response letters to deliver our decisions to members and/or providers within the regulatory timeframes set forth by the Centers for Medicare & Medicaid Services (CMS).
• Act as a subject-matter expert for cross-functional clinical reviews: digest complex concepts and regulations and communicate them effectively to different stakeholders, including senior-level leadership.
• Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
• Work closely with data scientists, engineers and operational teams to create sustainable and scalable solutions.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.
• Identify and review potential program efficiencies and opportunities.
• Continue to analyze existing policies to ensure accuracy and proper execution.
• Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.

You will love this job if:

• You want to make an impact. You thrive off of helping others, and want your work to make a difference in our members' lives.
• You are a team player. You enjoy partnering with others, and want to work collaboratively to find new solutions.
• You are a strong communicator. You have strong verbal and written communication skills that foster trust, knowledge sharing, and progress.
• You are detail-oriented. You pay attention to the small things, while understanding how they fit into the bigger picture.
• You are motivated to learn. There is no shortage of technical, clinical, and operational skills to learn at Clover.
• You are curious. You like to do research when you don't know an answer. You ask the hard questions and you don't sweep problems under the rug.

You should get in touch if:

• You hold a CCS certification or similar inpatient coding certification; required
• Deep knowledge and understanding of DRG pricing methodology; required.
• You have current or previous nursing or firsthand clinical experience; preferred.You have 5+ years of experience in clinical coding; preferred
• Medicare or Medicare Advantage Payment Integrity or claims operations experience; preferred
• You are technologically savvy with strong computer skills in Excel and PowerPoint.
• Knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus.

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Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.
About Clover: 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 and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one's identity. All of our employee's points of view are key to our success, and inclusion is everyone's responsibility.