Medical Claims Auditor Remote - USA

The Special Investigation Unit (SIU) is a motivated, collaborative team at the intersection of Compliance, Payment Integrity, and Data Infrastructure. The SIU ensures that Clover monitors, identifies, and investigates instances of healthcare fraud, waste and abuse (FWA). Join us as we discover new opportunities to enhance the fight against FWA. About the Role As a Medical Claims Auditor within our Special Investigations Unit, you will play a critical role in ensuring that Clover continues to build and scale a compliant, effective FWA audit program. You will be joining a fast‑growing, fast‑moving startup at the intersection of healthcare and technology, where you will have the opportunity to develop both your policy and operational skills. A successful Medical Claims Auditor will have a broad coding knowledge base, including but not limited to: DME, Outpatient, ASC and Physician correct coding. This position focuses specifically on Medicare coding policies. Responsibilities Partner with Clinical, Claims, and SIU peers to review claims for billing and coding related issues on a retrospective basis that currently drive inaccurate payments to providers or indicate FWA. Identify control opportunities to mitigate FWA. Identify possible audit opportunities. Support annual FWA audit goals. Support provider conversations around FWA audit findings. Manage overall audit workload to ensure timely and accurate audit results. Work closely with senior team members and management on targeted projects and initiatives. Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi‑discipline teams. Success Metrics By the end of your initial 90‑day period, you will have demonstrated a strong understanding of our review process and be able to navigate Clover’s systems effectively. By 6 months, you will be working autonomously on provider reviews. Continued success anchors on developing a deep understanding of the workflows that support our SIU cases and reviews while maintaining regulatory compliance standards. Qualifications 3+ years of coding and auditing experience; experience with CMS regulations preferred. Certified Professional Coder (CPC) or other coding certification is a plus. Strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI. Experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite. Prior experience working in health insurance; Medicare Advantage is a plus. Benefits Overview Financial Well‑Being : Competitive base salary, equity opportunities, performance‑based bonus program, 401k matching, and regular compensation reviews. Physical Well‑Being : Comprehensive medical, dental, and vision coverage. Mental Well‑Being : Initiatives such as No‑Meeting Fridays, monthly company holidays, mental health resources, and a generous flexible time‑off policy. Remote‑first culture supports collaboration and flexibility. Professional Development : 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 and monthly cell phone & internet stipend. Paid parental leave for all new parents. 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 those who need it most. Equal Opportunity Employer We are an Equal Opportunity Employer. Diversity and inclusion are core to our success. All qualified applicants, regardless of race, gender identity, age, disability status, veteran status, sexual orientation, religion, or any other protected characteristic, will be considered for employment. The SanFrancisco FairChance Ordinance requires us to consider qualified applicants with arrest and conviction records. We are an E‑Verify company. #J-18808-Ljbffr