Senior Auditor, Clinical Coding Review

Job description

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...