Medical Claims Auditor

Clover Health is seeking a Medical Claims Auditor to join their Special Investigation Unit, which focuses on combating healthcare fraud, waste, and abuse. In this role, you will review claims for billing and coding issues, both before payment and retrospectively, to ensure accurate provider payments and prevent fraud. The position requires a strong knowledge of coding, particularly in areas such as Durable Medical Equipment, Outpatient services, Ambulatory Surgical Centers, and Physician coding, with an emphasis on Medicare policies. You will utilize internal AI tools and predictive models to identify unusual billing patterns and collaborate with Data Science and Engineering teams to validate claims flagged by AI. The role involves identifying opportunities for systemic prepayment edits and supporting annual audit goals by prioritizing significant reviews. This remote position is ideal for individuals with a solid background in medical coding and a keen interest in enhancing compliance and operational processes within a fast-paced startup environment.