About the job
The Special Investigation Unit (SIU) at Clover Health is a dynamic and collaborative team that operates at the crossroads of Compliance, Payment Integrity, and Data Infrastructure. Our mission is to vigilantly monitor, identify, and investigate instances of healthcare fraud, waste, and abuse (FWA). We invite you to join us in uncovering innovative ways to strengthen our defenses against FWA!
As a Medical Claims Auditor within our esteemed Special Investigations Unit, you will be integral in enhancing Clover's capacity to sustain and expand a compliant and effective FWA audit program. You will be a part of a rapidly growing startup that merges healthcare with cutting-edge technology, allowing you to refine your policy and operational expertise. The ideal candidate will possess extensive coding knowledge across various domains, particularly focusing on Medicare coding policies.
Your Responsibilities:
- Collaborate with Clinical, Claims, and SIU colleagues to retrospectively review claims for billing and coding discrepancies that may lead to inaccurate provider payments or indicate FWA.
- Identify control opportunities to prevent FWA.
- Spot potential audit opportunities.
- Assist in achieving annual FWA audit objectives.
- Engage in conversations with providers regarding FWA audit outcomes.
- Oversee your audit workload to guarantee timely and precise audit results.
- Work closely with senior team members and management on focused initiatives.
- Foster effective communication while building trust and lasting partnerships across diverse teams.
Performance Expectations:
- Within your first 90 days, you'll demonstrate a solid grasp of our review processes and efficiently navigate the various Clover systems.
- By the six-month mark, you will be conducting provider reviews independently.
- Ongoing success in this role relies on developing a profound understanding of the workflows that underpin our SIU cases and reviews while adhering to regulatory compliance standards.
Ideal Candidates Will Have:
- A minimum of 3 years of coding and auditing experience, with a preference for familiarity with CMS regulations.
- Certification as a Professional Coder (CPC) or other relevant coding credentials is advantageous.
- A robust understanding of the National Rules of Correct Coding.

