Clover Health

Role Description 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 Inpatient Clinical Coder 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 Inpatient Clinical Coder, 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. Qualifications - You hold a CCS or CIC certification; required. - Knowledge of DRG pricing methodology; required. - You have 1-2 years of experience in inpatient clinical coding; preferred. - Medicare or Medicare Advantage payment integrity or claims operations experience; preferred. - You are technologically savvy with strong computer skills in Excel and PowerPoint. Benefits - Financial Well-Being: Competitive base salary and 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, access to mental health resources, 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 all new parents, and much more! Company Description 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.

• Own cloud infrastructure end-to-end across our cloud environments, staying hands-on with IaC, CI/CD, and observability alongside the team. • Own the SDLC surface area (dev environments, lower envs, release mechanics, monitoring and response) so engineers can ship in minutes rather than days. • Build the substrate that lets AI agents observe, reason, and act on business systems with safe defaults, and the rails that let AI-assisted apps from people outside of tech be deployed and supported without becoming operational liabilities. • Participate in security operations alongside our SecOps team on CSPM, threat management, and patch management as the infrastructure-side owner of remediations. • Frame infrastructure decisions in terms of business outcomes (operational efficiency, financial impact, clinical results), and make progress and tradeoffs visible to leadership as a natural byproduct of how you work. • Lead and develop a small, high-impact team, and operate as a peer to our SecOps, Data, IT Systems, and App Engineering leaders as a unifying technical force across the org.

• First-Pass Accuracy Architecture: Lead the technical design and implementation of strategic configuration logic to ensure flawless first-pass adjudication. Ensure that complex member benefits and provider contract terms are perfectly synchronized with our accuracy goals. • Strategic Process Optimization: Identify and address configuration gaps by optimizing edit logic and implementing enhanced precision-based review triggers to ensure payment precision at the point of initial intake. • Evolution of Automated Solutions: Lead the integration of automated solutions to improve efficiency and accuracy in plan configuration. Utilize data-forward strategies to analyze configuration data, identify trends, and proactively mitigate payment inaccuracies. • Cross-Functional Synergy: Act as the primary strategic bridge between Configuration, Payment Integrity, Clinical Review, and Compliance. Ensure that plan designs and regulatory requirements are translated into actionable, high-precision configuration logic. • Lean Team Leadership: Provide hands-on, "player-coach" leadership for a small, high-impact team of specialists, fostering a culture of excellence, accountability, and continuous technical learning. • Technical Documentation: Develop best practices and documentation for advanced configuration procedures.

• Architect and execute comprehensive test plans to validate that member benefits, provider contract terms, and general edits—including LCD, NCD, and NCCI coding edits—are configured accurately within our systems. • Develop and execute complex, scenario-based testing models that simulate real-world medical encounters to ensure configuration holds up under various coding conditions and modifier applications. • Collaborate with the Senior Manager to provide detailed "failed-test" analysis and comprehensive impact assessments, documenting the financial and operational risk where configuration logic diverged from intended outcomes. • Manage the technical validation lifecycle across testing and UAT environments to ensure "zero-defect" deployments into the live production environment. • Simulate scenarios in a test environment to confirm the root cause of payment variances and validate that proposed configuration fixes work as intended. • Support the evolution of our testing frameworks by utilizing LLMs to create test scenarios, summarize configuration requirements, and identify edge cases in complex reimbursement logic. • Work closely with the core Configuration, Payment Integrity, and internal stakeholders to move logic from testing to production with high confidence. • Maintain detailed records of test results, training materials, and configuration procedures to ensure transparency and compliance with CMS regulations.

Role Description We are looking for a highly analytical Senior Claims Researcher to join our Claims Excellence team. Reporting directly to the Director, Claim Payment Accuracy, you will be a key individual contributor responsible for executing the high-level technical audits and testing that ensure our claims are paid correctly the first time. You are not just a claims processor; you are a "claims detective" who enjoys digging into complex data to find the "why" behind payment variances. In this role, you will perform deep-dive research and quality audits across our adjudication ecosystem, focusing on the intersection of provider contracts, benefit design, and system configuration. As a Senior Claims Researcher, you will: - Technical Quality Auditing: Execute the monthly audit plan as designed by the Director, performing detailed reviews of claims to ensure they align with provider contracts, benefit rules, and pricing guidelines. - Root Cause Research: Go beyond identifying errors; perform deep-dive research into HealthEdge HRP and Source to determine if a variance was caused by configuration logic, manual intervention, or policy misinterpretation. - Data-Driven Reporting: Compile and present audit findings that highlight trends and "enterprise risk" areas, categorizing errors to provide the Director with actionable insights for executive-level reporting. - AI-Enabled Oversight: Support the implementation of AI and Machine Learning auditing tools by providing the "human-in-the-loop" feedback necessary to train and refine automated accuracy models. - BPaaS & Configuration Collaboration: Partner closely with our external BPaaS stakeholders and internal Configuration teams to communicate audit findings, utilizing JIRA to track the lifecycle of an error from identification to systemic resolution. - Strategic Testing: Act as the final safeguard for Clover’s adjudication accuracy, ensuring that the system's "real-world" output matches the contractual and benefit intent. Success in this role looks like: - By the end of your initial 90-day period: You will have mastered the nuances of Clover’s HealthEdge HRP and Source environments and will be actively executing the monthly audit cycle, performing both random and risk-based judgmental audits to ensure baseline payment accuracy. - By 6 months: You will be recognized as the "SME of Record" for identifying systemic payment trends across pricing and benefits. You will also be actively leveraging AI tools like Claude, Gemini, and ChatGPT to build out ongoing monitoring and oversight trends that identify high-impact risks to support judgmental sampling and targeted audits. - Continued success: You will be at the forefront of "Audit 2.0," utilizing AI-forward strategies to increase the scope and speed of your research. Your work will directly contribute to Clover’s commitment to achieving top-tier payment precision and the reduction of billing friction for our members and provider partners. Qualifications - 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication. - Current coding certification is required (CPC, CCS, COC, or CIC). - Deep technical proficiency in HealthEdge HRP and Source. - A "researcher's mindset"—naturally curious, detail-oriented, and persistent in finding the root cause of a technical problem. - Extremely AI-forward and excited to use technology and LLMs (Claude, Gemini, ChatGPT) to move away from manual, spreadsheet-based auditing. - Strong communicator who can translate complex technical findings into clear, actionable reports for leadership. Benefits - Financial Well-Being: Competitive base salary and 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, access to mental health resources, 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 all new parents.

• Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations. • Design and oversee a robust, multi-layered audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms. Ensure that all findings are fed into a continuous improvement loop to enhance systemic accuracy. • Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation. You will independently utilize advanced LLMs (such as Claude, Gemini, and ChatGPT) to analyze oversight trends and develop data-driven criteria for judgmental sampling and targeted audits. • Serve as the lead for global payment accuracy oversight regarding our external BPaaS partner, holding the vendor to world-class standards through global accuracy reviews and data-driven performance monitoring. • Act as the strategic bridge between Clinical, Claims, A&G, UM, Compliance, Quality, and the Configuration team, ensuring that clinical intent, benefit design, and contractual terms are perfectly synchronized in the final payment adjudication.

• Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations. • Serve as the authority on Medicare guidelines, specifically interpreting and operationalizing NCDs, LCDs, and general national coding guidelines. • Serve as the primary oversight for external vendor performance regarding policy monitoring and accuracy. Hold partners to world-class standards through data-driven performance reviews and collaborative workflow design. • Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies. Utilize advanced LLMs (such as Claude, Gemini, and ChatGPT) to conduct regular deep research on ongoing industry trends. • Partner with the Configuration and Data Science teams to ensure that clinical and reimbursement policy intent is perfectly synchronized with technical adjudication. • Act as the strategic bridge between Clinical, Claims, and Compliance teams to ensure a unified vision of payment excellence.

• You are accountable for ensuring that the data our customers provide is complete, reliable, and continuously useful for the clinical workflows, analytics, and provider-facing tools built on top of it. • You will work directly with customer data and technical teams as their primary counterpart at CPH, and you will build the integration infrastructure that lets us scale as our customer base grows. • You are accountable for whether the data actually works for products, for providers, and for customers, and for recognizing when it does not. • Claims, pharmacy, labs, enrollment, provider alignment, and clinical data should be fit for purpose in every market we operate in. You are accountable for that outcome across the full lifecycle, from initial onboarding through ongoing data health. • You work directly with customer data and technical teams, driving execution, resolving quality issues, and building the kind of trust that comes from deep technical engagement. You balance hands-on partnership with standard approaches that work across the customer base. • Every integration you run should make the next one faster. You will build playbooks, standard data expectations, reusable patterns, and monitoring frameworks that make onboarding predictable and scalable, leveraging AI to automate validation and reduce manual effort as the customer base grows. • You will manage multiple customer integrations in parallel, making prioritization decisions and maintaining momentum across a growing portfolio. • You work closely with data management, engineering, analytics, and clinical product teams to close the gap between data arriving and data being useful for the workflows that depend on it. • You will leverage AI to accelerate everything, from investigating data to triaging quality issues. You build AI first repeatable patterns that scale to a growing number of customers and data sources.

• Own and evolve the design system as a product, including components, patterns, and usage standards. • Build and maintain reusable UI primitives and interaction patterns that scale across teams. • Proactively manage frontend UX-related technical debt, resolving quality gaps and inconsistencies that slow development. • Conduct coded prototyping for complex workflows using synthetic or mock data, especially for data-dense or AI-enabled experiences. • Improve experience quality and consistency across motion, responsive behavior, and mobile contexts. • Partner closely with Design and Product during discovery to validate feasibility and reduce downstream rework. • Act as the interface between design intent and frontend implementation, resolving ambiguity and aligning on constraints. • Contribute production-quality code and collaborate with engineering on system-level frontend decisions.

• Define, Measure, and Optimize Unit Economics: Partner with Actuarial, Growth, and Ops teams to develop a nuanced understanding of unit economics. You will define and track multi-year cohort and plan-level views, while most importantly, working to optimize unit costs and growth levers. • Lead Planning and Forecasting: Partner with leadership, actuarial and operations to develop annual plans and quarterly forecasts. • Drive the Business “Rhythm”: Partner with leadership to review core reporting and initiative progress consistently. You will leverage the monthly close process to ensure alignment with the budget and maintain rigorous scrutiny of ROI for all operational activities. Most importantly, you will ensure insights lead to action. • Evaluate Strategic Projects: Assess the value of high-stakes programs. Once capital is allocated, you will track these initiatives to ensure they deliver the projected value.