Payment Integrity Analyst

About Clover Health and the Payment Integrity Team

The Payment Integrity team at Clover Health comprises innovative thinkers working at the intersection of the company's provider network, claims, and technology teams. This team is crucial for ensuring that Clover pays claims accurately, with a primary 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 requires strong technical knowledge to build complex SQL queries for sizing and deploying high-value individual cost-savings concepts, as well as assisting with identifying these audit opportunities. Additionally, you will be responsible for creating monthly, quarterly, and annual Payment Integrity financial reports, along with ad-hoc reports to support operations.

Key Responsibilities of a Payment Integrity Analyst

• Identify, develop, and deploy a portfolio of cost-saving concepts and initiatives that drive specific and measurable results for Clover Health.
• Translate individual concepts into SQL code for automated deployment against Clover's pending and/or paid claims data.
• Support existing and develop new medical record review and administrative hold concepts/edits to achieve 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 team members to create SQL code for minor reporting or quick analysis.
• Support 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 data-related aspects, including claims, enrollment, and clinical data.
• Partner with data and engineering teams to investigate data issues intersecting with payment integrity processes.
• Generate monthly, quarterly, and annual payment integrity financial reports, as well as ad-hoc reports to support operational functions.

Success Metrics for this Role

First 90 Days:

• Data Fluency: Achieve a deep understanding of Clover’s specific claims, enrollment, and clinical data schemas.
• Technical Integration: Demonstrate proficiency in the tech stack, including expert-level SQL and GitHub protocols (branching, merging, and pull requests).
• Initial Concept Development: Translate at least two net-new medical cost-saving concepts into functional SQL code for automated deployment.

First 6 Months:

• Portfolio Growth: Own and maintain the full portfolio of Clover’s automated cost-saving concepts.
• Reporting Autonomy: Generate accurate monthly and quarterly Payment Integrity financial reports with minimal oversight.
• Cross-Functional Influence: Lead discussions with clinical staff and billing experts to turn complex data into actionable operational improvements.
• Workflow Optimization: Effectively leverage AI-assisted tools to accelerate query writing and data cleaning, demonstrating an increase in team velocity.

Future Success:

• Subject Matter Expertise: Become the primary contact for data and engineering teams when payment integrity processes intersect with broader data issues.
• Policy Evolution: Successfully advocate for and implement systemic changes to claims payment policies based on your data-driven insights.
• Scalability: Develop a robust library of automated audits that require minimal maintenance while catching high-value payment errors at scale.

Qualifications We're Looking For

• 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.
• Expertise in 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.
• Working knowledge of CMS rules and regulations.

Benefits and Perks at Clover Health

Clover Health offers a comprehensive benefits package designed to support the holistic well-being of its employees:

Financial Well-Being:

• Competitive base salary and equity opportunities.
• Performance-based bonus program.
• 401k matching.
• Regular compensation reviews.

Physical Well-Being:

• Comprehensive medical, dental, and vision coverage.

Mental Well-Being:

• No-Meeting Fridays.
• Monthly company holidays.
• Access to mental health resources.
• Generous flexible time-off policy.
• Remote-first culture supporting collaboration and flexibility.

Professional Development:

• Learning programs and mentorship.
• Professional development funding.
• 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.
• Paid parental leave for all new parents.
• And much more!

About Clover Health

Clover Health is reinventing health insurance by combining the power of data with human empathy to keep members healthier. The company believes the healthcare system is broken and has created custom software and analytics to empower clinical staff to intervene and provide personalized care. Clover Health puts its members first, measuring success by the quality of life of the people served. The team consists of passionate, mission-driven individuals with diverse expertise, working together to solve the complex problem of healthcare.

Diversity & Inclusion have been key to Clover’s success since its inception. They are an Equal Opportunity Employer, valuing employees with different strengths, experiences, perspectives, opinions, and backgrounds. Diversity includes race, gender identity, age, disability status, veteran status, sexual orientation, religion, and many other aspects of identity. All employee points of view are crucial to success, and inclusion is everyone's responsibility.

Clover Health is an E-Verify company and, pursuant to the San Francisco Fair Chance Ordinance, will consider qualified applicants with arrest and conviction records.

Key skills/competency

• SQL
• Healthcare Claims Analysis
• Data Analytics
• Payment Integrity
• Medical Cost Savings
• Financial Reporting
• GitHub
• CMS Regulations
• AI-assisted Workflows
• Cross-functional Collaboration