The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider network, claims, and technology teams. The Payment Integrity team ensures that Clover pays claims in an accurate manner, with a particular focus on reducing inappropriate medical spending.
As a Payment Integrity Analyst, you will be responsible for identifying, researching, developing, and maintaining a portfolio of medical cost savings opportunities. This position will leverage strong technical knowledge to build complex SQL queries to size and ultimately deploy high-value individual cost-savings concepts as well as assist with the identification of these audit opportunities. In addition, the Senior Associate will be responsible for the creation of monthly, quarterly, and annual Payment Integrity financial reports as well as ad-hoc reports to support operations.
As a Payment Integrity Analyst, you will:
- Identify, develop, and deploy a portfolio of cost-saving concepts and initiatives that drive specific and measurable results for Clover.
- Translate individual concepts into SQL code that can be deployed in an automated fashion against Clover's pending and/or paid claims data.
- Support existing and develop new medical record review and administrative hold concepts/edits to drive specific and measurable results.
- Lead cross-functional discussions with billing experts, clinical staff, and operations managers to translate complex claims data into operational improvements.
- Train other members of the team to create SQL code for minor reporting or quick analysis.
- Support the team with daily operational tasks such as triaging Salesforce tickets, assisting with audit letter creation, and reimbursement processing.
- Influence senior leadership to adopt new policies, procedures, concepts, and initiatives to drive claims payment accuracy and medical cost containment.
- Act as a subject matter expert on all things data-related, including claims, enrollment, and clinical. Partner with data and engineering teams to investigate data issues when they intersect with payment integrity processes.
- Generate monthly, quarterly, and annual payment integrity financial reports as well as ad-hoc reports to support operational functions.
Success in this role looks like:
- How is success measured in the first 90 days?
- Data Fluency: Gaining a deep understanding of Clover’s specific claims, enrollment, and clinical data schemas.
- Technical Integration: Demonstrating proficiency in the tech stack, including expert-level SQL and GitHub protoc