DRG Validation Auditor

The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Tech teams. The Payment Integrity team ensures that Clover pays claims in an accurate manner, with a particular focus on reducing inappropriate medical spend.

As an DRG Validation Auditor at Clover Health, you will play a key role ensuring that Clover is able to continue to build and scale a compliant, efficient and profitable program. You will work to ensure quality assurance standards and regulatory policy are reflected in 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. The Associate - Inpatient Coder coordinates the identification of provider DRG denials and upcoding.

As an DRG Validation Auditor, you will:

• 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 inpatient services.
• Participate in collaborative discussions with MDs to verify the clinical rationale behind billed procedures.
• Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.
• Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.

Success in this role looks like:

• By the end of your initial 90-day period, you will have demonstrated a strong understanding of clinical coding practices and medical records review, while assisting our team in areas of DRG validation.
• By 6 months, you will be working autonomously to execute within our clinical review workflows and will have developed strong interpersonal relationships across the organization.
• Continued success in this position anchors in on developing a deep understanding of the workflows that support our clinical review life cycle, while maintaining regulatory compliance standards.

You should get in touch if:

• You hold a CCS or CIC certification; required.
• Knowledge of DRG pricing methodology; required.
• You have at least 1 year of direct inpatient clinical coding experience.
• Medicare or Medicare Advantage payment integrity or claims operations experience; preferred
• You are technologically savvy with strong computer skills in Excel and PowerPoint.

Benefits Overview :

• Financial Well-Being : 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.
• Physical Well-Being : We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being : 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.
• Professional Development : Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.

Additional Perks:

• 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
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured 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: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

# LI-REMOTE

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

#LI-Remote

Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.

A reasonable estimate of the base salary range for this role is:

$76,000—$99,000 USD