Payment Integrity Analyst

Clover Health

. Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge .

Posted 10/7/2026full-timeRemote • United StatesMid-LevelSenior💰 $76,900 - $100,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medicare Advantage claims adjudication and reimbursement, with strong SQL proficiency for data analysis and investigation. Capable of conducting thorough claims audits and research while maintaining organized documentation and effective communication.

Highest-signal resume keywords

Medicare Advantage Claims AdjudicationSQL ProficiencyClaims Audit ExperienceAnalytical Research SkillsAttention to Detail

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

SQL AnalysisClaims ExaminationPayment IntegrityReimbursement AnalysisData ReconciliationClaims ResearchCoding GuidancePayment Policy KnowledgeBenefit Provisions UnderstandingAI Tools Usage

Soft Skills

Clear CommunicationOrganizational SkillsJudgment in Data Handling

Tools & Technologies

ExcelAI Research Tools

Industry Keywords

Medicare AdvantageClaims DiscrepanciesProvider ContractsPayment PoliciesCompliance Review

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

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, internal payment policies, and configuration requirements
Identify effective dates, applicability, and unresolved source conflicts
Analyze claim and line detail, payment components, adjustments, reversals, and related claim history
Independently run SQL queries and adapt dates, filters, and claim selections
Seek evidence that could disprove suspected issues, including correctly paid comparison claims and alternative explanations
Document sources, validation steps, exclusions, payment impact, and unresolved questions for reproducible review
Use approved AI tools for research, query interpretation, and documentation while verifying outputs
Review and audit audit-tool outputs, identify false positives, and refine rules
Prepare findings for review and support recovery evaluation, operational resolution, and Compliance/Legal review
Contribute to recurring audits, monitor validated issues, and recommend improvements to investigation and testing processes

Requirements

What you’ll need

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
Strong practical knowledge of Medicare Advantage claims adjudication and reimbursement
Knowledge of benefit provisions, provider contracts, payment policies, and configuration impacts on payment outcomes
Ability to investigate payment discrepancies, test competing explanations, recognize exceptions, and distinguish suspected issues from supported findings
Ability to independently conduct defined investigations, identify missing information, and escalate complex or unresolved questions
Practical SQL proficiency and ability to navigate large relational database environments
Strong Excel skills and experience reviewing, filtering, comparing, and reconciling claims-level datasets
Hands-on experience using AI tools in analytical, research, or claims-related work, with sound judgment regarding verification and data handling
Clear written and verbal communication skills
Strong attention to detail and ability to manage multiple investigations with organized, traceable documentation
Experience with Medicare Advantage claims and reimbursement
Coding or reimbursement credentials are advantageous but not required

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