Responsibilities
- 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.
Requirements
- experience working with complex processes in a technical environment and synthesizing data for senior leadership
- 2+ years of experience with expert-level SQL proficiency and a deep background in healthcare claims analysis
- 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
- BA/BS degree or equivalent experience along with 5+ years of experience in the data and analytics space
- 2+ years of experience working in healthcare data, preferably Medicare related
- experience with GitHub (branching, merging, pull requests) and move-to-production protocols
- a working knowledge of CMS rules and regulations
