Medical Claims Auditor

Clover Health

. Review claims for billing and coding-related issues on a prepayment and retrospective basis .

Posted 10/27/2026full-timeRemote • United StatesMid-LevelSenior💰 $92,300 - $120,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in coding and auditing with a strong focus on compliance and fraud prevention. Proficient in utilizing AI tools for data analysis and collaborating with multidisciplinary teams to enhance audit processes.

Highest-signal resume keywords

Certified Professional Coder (CPC)Coding And Auditing ExperienceKnowledge Of Medicare Coding PoliciesExperience With CMS RegulationsData Analysis And AI Insights

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Coding KnowledgeAuditing ExperiencePrepayment AuditsClaims ReviewFraud PreventionData AnalysisSystemic Prepayment EditsControl Opportunities IdentificationCompliance FeedbackMedicare Advantage Experience

Soft Skills

CollaborationCommunicationPartnership BuildingWorkload ManagementProblem Solving

Tools & Technologies

AI ToolsClaims SystemsWorkflow Management ToolsMicrosoft OfficeGoogle Suite

Certifications & Qualifications

Certified Professional Coder (CPC)

Industry Keywords

CMS RegulationsNational Rules Of Correct CodificationDME CodingOutpatient CodingASC CodingPhysician Correct CodingHealth InsuranceFraud, Waste And Abuse (FWA)

About the role

Key responsibilities & impact

Review claims for billing and coding-related issues on a prepayment and retrospective basis
Partner with Clinical, Claims, and SIU peers to prevent inaccurate provider payments and disrupt fraud, waste and abuse
Use internal AI tools and predictive models to identify anomalous billing patterns, emerging trends, and targeted prepayment audits
Collaborate with Data Science and Engineering teams to validate AI-flagged claims and provide coding feedback to refine machine learning models
Identify control opportunities and implement systemic prepayment edits to mitigate fraud, waste and abuse
Identify audit opportunities through AI-assisted data analysis and manual case identification
Support annual FWA audit goals by prioritizing high-value reviews
Support provider conversations around FWA audit findings and translate complex data, AI insights, and prepayment denials into compliance feedback
Manage audit workload to deliver timely and accurate results within strict prepayment turnaround times
Work with senior team members and management on targeted projects and initiatives
Build partnerships across multidisciplinary teams
Navigate Clover systems, conduct provider reviews autonomously, and support case/opportunity identification

Requirements

What you’ll need

3+ years of coding and auditing experience
Experience with CMS regulations preferred
Certified Professional Coder (CPC)
Strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI
Experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite
Prior experience working in health insurance
Medicare Advantage experience is a plus
Broad coding knowledge including DME, Outpatient, ASC and Physician correct coding
Knowledge of Medicare coding policies

Benefits

Comp & perks

Competitive base salary
Equity opportunities
Performance-based bonus program
401k matching
Regular compensation reviews
Comprehensive medical, dental, and vision coverage
No-Meeting Fridays
Monthly company holidays
Mental health resources
Generous flexible time-off policy
Remote-first culture
Learning programs
Mentorship
Professional development funding
Regular performance feedback and reviews
Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
Reimbursement for office setup expenses
Monthly cell phone & internet stipend
Collaboration with global teams
Paid parental leave for all new parents