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 protocols (branching, merging, and pull requests).
- Initial Concept Development: Translating at least two net-new medical cost-saving concepts into functional SQL code for automated deployment.
- How is success measured in the first 6 months?
- Portfolio Growth: Owning and maintaining the full portfolio of Clover’s automated cost-saving concepts.
- Reporting Autonomy: Generating accurate monthly and quarterly Payment Integrity financial reports with minimal oversight.
- Cross-Functional Influence: Leading discussions with clinical staff and billing experts to turn complex data into actionable operational improvements.
- Workflow Optimization: Effectively leveraging AI-assisted tools to accelerate query writing and data cleaning, showing an increase in team velocity.
- How will success be measured in the future?
- Subject Matter Expertise: Being the "go-to" person for the data and engineering teams when payment integrity processes intersect with broader data issues.
- Policy Evolution: Successfully advocating for and implementing systemic changes to claims payment policies based on your data-driven insights.
- Scalability: Developing a robust library of automated audits that require minimal maintenance while catching high-value payment errors at scale.
You should get in touch if:
- You have experience working with complex processes in a technical environment and synthesizing data for senior leadership.
- You have 2+ years of experience with expert-level SQL proficiency and a deep background in healthcare claims analysis.
- You are expert at leveraging AI-assisted workflows to accelerate complex query writing and data cleaning. Highly skilled in translating claims data into actionable insights using Excel, Visio/Lucid, and Google Suite.
- You hold a BA/BS degree or equivalent experience along with 5+ years of experience in the data and analytics space.
- You have 2+ years of experience working in healthcare data, preferably Medicare related.
- You have experience with GitHub (branching, merging, pull requests) and move-to-production protocols.
- You have a working knowledge of CMS rules and regulations.
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.
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.
A reasonable estimate of the base salary range for this role is $90,000 to $120,000. 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.