Inpatient Coder Senior Associate

Summary

Join Clover Health as a Senior Associate - Inpatient Coder and play a key role in ensuring the accuracy of medical claim payments. Partner with cross-functional teams to review claims, identify overpayments, and prepare response letters to members and providers. Act as a subject matter expert, providing insights into complex regulations and communicating effectively with various stakeholders. Work with data scientists and engineers to develop scalable solutions and identify program efficiencies. Analyze existing policies to ensure accuracy and proper execution. Demonstrate a strong understanding of clinical coding practices and medical records review within 90 days, and become a trusted subject matter expert within 6 months.

Requirements

• You hold a CCS certification or similar inpatient coding certification; required
• You have a deep knowledge and understanding of DRG pricing methodology; required

Responsibilities

• 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

Preferred Qualifications

• You have current or previous nursing or firsthand clinical experience; preferred
• You have 5+ years of experience in inpatient clinical coding; preferred
• You have Medicare or Medicare Advantage payment integrity or claims operations experience; preferred
• You are technologically savvy with strong computer skills in Excel and PowerPoint
• You have knowledge of statistical methods used in the evaluation of healthcare claims data and SQL a plus

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