Responsibilities
- Execute Claim Reprocessing Cycles: Facilitate the aggregation of high-volume claim batches for reprocessing. Utilize advanced data management and spreadsheeting techniques to merge, review, and validate cycles of claim adjustments, ensuring precision prior to final submission.
- Perform Reprocessing Reconciliations: Facilitate backend controls to audit the accuracy of batch-reprocessed claims. Conduct comprehensive reconciliations to ensure that all expected adjustments are captured and processed without discrepancy.
- Manage Recovery Posting & Resolution: Reconcile claims data to determine the accuracy and completeness of reprocessed claims. Oversee the audit software environment to control resolution tracking and ensure official recovery recognition aligns with Payment Integrity standards.
- Optimize Audit Letter Workflows: Manage the end-to-end administration of audit communications, including the extraction of data, secure SFTP transfers, rigorous proofing of member/provider letters, and the successful upload of files to external systems and vendors.
- Maintain Status Reconciliation: Perform ongoing monitoring and maintenance of audit software to validate the integrity of the audit population. Proactively research and resolve aging audits to minimize inventory lag and ensure timely recovery.
- Collaborate Across Functions: Partner with the Claims Adjustment Team, Provider Services, and key internal stakeholders to resolve escalated payment issues and optimize recovery outcomes while preserving strong provider partnerships.
- Drive Process Excellence: Develop and refine process documentation, workflows, and standard operating procedures (SOPs) to strengthen team capabilities and maximize operational efficiency.
Requirements
- 3+ years of experience working with large datasets, including reconciliations, data validation, and transfers in a high-volume environment.
- Technically savvy and comfortable learning new systems, tools, and workflows quickly.
- Strong attention to detail and a track record of catching discrepancies and ensuring data accuracy.
- Supported financial audits within a healthcare setting, with exposure to claims data, payments, or audit workflows.
- Confident in Excel or Google Sheet, specifically in processing and cleaning extensive data volumes to ensure accuracy, completeness, and integrity. (e.g., pivots, lookups).
Nice to Have
- Experience with SQL or healthcare audit/analytics tools.
Benefits
- 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.
- 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
Team
Structure: The Payment Integrity team is a motivated, collaborative team sitting at the intersection of Clover's provider relationship operations, data infrastructure, and software.
Additional Information
- 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.
