Payment Integrity Analyst
New
C
Clover HealthHealthcare claims
Remote - USAFull-TimeMiddle
SalaryA reasonable estimate of the base salary range for this role is: $76,900 — $100,000 USD
Apply NowOpens the employer's application page
Job Details
- Experience
- 3–5 years of relevant experience
- Required Skills
- SQLMicrosoft Excel
Requirements
- Bring 3–5 years of relevant experience in payment integrity, reimbursement analysis, claims audit, complex claims research, claims examination, or related work, including direct Medicare Advantage experience.
- Have practical knowledge of Medicare Advantage claims adjudication and reimbursement, including the effects of benefit provisions, provider contracts, payment policies, and configuration.
- Be able to investigate payment discrepancies, test competing explanations, recognize exceptions, and distinguish suspected issues from supported findings.
- Independently work through defined investigations, identify missing information, and escalate complex or unresolved questions with a clear explanation of needed evidence.
- Have practical SQL proficiency and be able to navigate large relational database environments and recognize unexpected duplication, exclusions, or changes in results.
- Have strong Excel skills and experience reviewing, filtering, comparing, and reconciling claims-level datasets.
- Have hands-on experience using AI tools in analytical, research, or claims-related work, with sound judgment about verification and appropriate data handling.
- Communicate clearly in writing and verbally, and explain complex findings to technical and operational partners.
- Maintain attention to detail and organized, traceable documentation while managing multiple investigations.
Responsibilities
- Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge.
- Review claims populations identified through SQL analysis and distinguish payment discrepancies from valid exceptions, data issues, and correctly adjudicated claims.
- Research CMS/NCCI and other coding guidance, provider contract terms, benefit documents, and internal payment policies and configuration requirements.
- Analyze claim and line detail, payment components, adjustments, reversals, and related claim history to assess expected payment outcomes.
- Independently run SQL queries and make targeted changes to dates, filters, and claim selections.
- Document applicable sources, validation steps, exclusions, supported payment impact, and unresolved questions.
- Use approved AI tools to support research, query interpretation, and documentation while verifying outputs.
- Review audit-tool outputs, identify false positives, and refine rules to improve precision.
- Prepare findings for review and support recovery evaluation, operational resolution, and Compliance/Legal review as needed.
- Contribute to recurring audits and recommend improvements to investigation and testing processes.
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