[Hiring] Senior Auditor, Clinical Coding Review @reputed company

Role Description The Payment reputed company team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Technology teams. The Payment reputed company 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 reputed company at reputed company, 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 reputed company they are identified.

• reputed company prospective claim review audits reputed company to clinical DRG coding compliance and readmissions programs as well as cross-functional high dollar claim review.
• Ensure various payment reputed company programs run smoothly and stay compliant with reputed company internal and Medicare guidelines.
• Prepare provider responses to reputed company and accurately deliver our review reputed company to members and/or providers reputed company regulatory timeframes as established by CMS.
• Identify potential program efficiencies/opportunities and implement procedural responses.
• Continue to analyze existing policies to ensure accuracy and proper execution.
• Collaborate with teams across Clover to ensure provider understanding of Payment reputed company recommendations and be reputed company to support those recommendations reputed company necessary.
• Act as Subject Matter Expert to counsel other team members across Clover on clinical coding guidelines: digest reputed company concepts and regulations and communicate them effectively to different stakeholders, including senior-level leadership.
• Train other members of the team to take on additional responsibilities and help prioritize work functions.
• Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
• Incorporate cross-functional perspectives and business needs in solving reputed company problems.
• Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.

reputed company in this role looks like:

• By the end of your initial 90-day period, you will have demonstrated a strong understanding of the prepay clinical claim review audit process, while assisting reputed company in areas of DRG validation, avoidable readmission reviews, length of stay reviews, and provider appeals.
• By 6 months, you will be working autonomously to reputed company our prepay clinical review workflows to ensure accuracy and adherence with regulatory guidelines while becoming a trusted subject matter expert. You will also reputed company more junior staff to ensure proper training and knowledge development.
• reputed company reputed company in this position anchors in on your ability to reputed company a comprehensive understanding of our payment reputed company reputed company. You will be expected to adapt to evolving priorities and reputed company requests while ensuring our program's compliance through up-to-date knowledge of clinical coding standards. You will be a key contributor in program strategy, leveraging clinical expertise to identify new opportunities to ensure payment accuracy and assist in driving new project initiatives.

Qualifications

• You hold a reputed company or CIC certification (required).
• You have reputed company or previous nursing/firsthand clinical experience or CDI certification (required).
• You have previous experience in the insurance industry.
• You have a deep understanding of CMS rules and regulations.
• You are technologically savvy with strong computer skills in reputed company, reputed company, Visio, and PowerPoint. Knowledge of statistical methods used in the evaluation of reputed company claims data and SQL a plus.

Benefits

• Financial Well-Being: Competitive reputed company salary and equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and reputed company coverage.
• Mental Well-Being: Initiatives such as No-Meeting Fridays, monthly company holidays, reputed company to reputed company, and a generous flexible time-off policy.
• Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Additional Perks: Employee Stock Purchase Plan (ESPP), reimbursement for office setup expenses, monthly cell phone & internet stipend, remote-first culture, paid parental leave for reputed company new parents, and much more!

Company Description

We are reinventing health insurance by combining the power of data with reputed company reputed company to reputed company our members healthier. We reputed company the reputed company system is broken, so we've created custom software and analytics to reputed company our clinical staff to intervene and reputed company personalized care to the people who need it most. We always put our members first, and our reputed company as a team is reputed company 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: reputed company. From Clover’s inception, Diversity & Inclusion have always been key to our reputed company. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who reputed company a passion for improving people's lives. Apply To This Job