Associate, Payment Integrity

Summary

Join Clover Health's Payment Integrity team as an Associate for Payment Integrity Vendor Management and oversee the day-to-day operations of cost containment vendors. Ensure adherence to service-level agreements and Clover's internal policies, maximizing vendor ROI. Monitor, evaluate, and report on overpayment inventory, ensuring accuracy and compliance. Resolve complex claim payment issues and manage workflows, focusing on efficiency improvements. Within 90 days, integrate into the team, build relationships, and understand key work streams and audit concepts. Within 6 months, work autonomously, demonstrating deep workflow understanding and compliance. Future success is measured by accuracy, meeting targets, and process improvements.

Requirements

• Hold a BA/BS degree or equivalent experience along with 2+ years of experience in the healthcare industry, with deep exposure to Payment Integrity and Medicare Advantage
• Have 2+ years of experience billing, coding, processing, and/or auditing claims along with knowledge of correct coding guidelines (CPT, HCPCS, DRG, and ICD 9/10) and reimbursement methodologies (FFS/professional, APC, DRG, etc.)
• Be technologically savvy with strong computer skills in Access, Excel, Visio, PowerPoint and basic knowledge of SQL
• Have a working knowledge of CMS rules and regulations
• Have experience with payment integrity vendor business partners

Responsibilities

• Oversee day-to-day operations of Clover's cost containment vendors
• Serve as point-of-contact between external vendors and various operations teams within Clover
• Monitor, evaluate, and report on overpayment inventory to ensure for findings accuracy, adherence to SLA's, and compliance with Clover P&P's
• Review and approve vendor overpayment identifications prior to pursuit
• Identify, research, and resolve complex and escalated claim payment issues originating from vendor findings
• Manage workflows and processing of vendor identifications from quality review through recovery, with a focus on developing efficiencies for future growth

Preferred Qualifications

• Coding certification through AAPC or AHIMA a plus
• Knowledge of statistical methods used in the evaluation of healthcare claims data preferred
• Google Sheets and Docs are a plus
• Be available during Eastern/Central US business hours; candidates in these time zones preferred

Benefits

• Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities
• Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions
• We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage
• We understand the importance of mental health in fostering productivity and maintaining work-life balance
• To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy
• Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location
• Developing internal talent is a priority for Clover
• We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for all new parents