Inpatient Coder Associate, Payment Integrity

About the role

You will partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on both a prospective and retrospective basis to drive accurate payments to providers. You will proactively identify overpayments to ensure accurate claims payments on inpatient services while helping Clover continue to build and scale a compliant, efficient, and profitable program. In this role, you will coordinate the identification of provider DRG denials and upcoding opportunities. You will communicate effectively while building trust and lasting partnerships across multi-discipline teams, and you will communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification. Success in this role requires a commitment to maintaining quality assurance standards and regulatory policy within claims processing practices to drive value for every member.

Key facts

What you'll do

Proactively identify overpayments to ensure accurate claims payments on inpatient services.

Partner with Clinical, Claims, and Payment Integrity peers to review claims for DRG related issues on a prospective and retrospective basis that drive inaccurate payments to providers.

Communicate effectively both internally and externally to ensure accurate claims adjudication and proper provider notification.

Participate in collaborative discussions with MDs to verify the clinical rationale behind billed procedures.

Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.

Continued success in this position anchors in on developing a deep understanding of the workflows that support our clinical review life cycle, while maintaining regulatory compliance standards.

By the end of your initial 90-day period, you will have demonstrated a strong understanding of clinical coding practices and medical records review, while assisting our team in areas of DRG validation.

By 6 months, you will be working autonomously to execute within our clinical review workflows and will have developed strong interpersonal relationships across the organization.

Identify provider DRG denials and upcoding opportunities to support recovery and prevention of inappropriate payments.

Support the development and refinement of processes that improve the accuracy and efficiency of inpatient coding reviews.

Leverage technological savvy with strong computer skills in Excel and PowerPoint to manage and analyze coding data.

Collaborate with cross-functional stakeholders to resolve coding discrepancies and ensure alignment with regulatory requirements.

Champion best practices in clinical coding to strengthen the integrity of Clover's payment integrity program.

Assist in the analysis of trends related to DRG denials and upcoding to inform targeted interventions.

Contribute to the continuous improvement of clinical review workflows and documentation standards.

Requirements

You hold a CCS or CIC certification; required.

You have knowledge of DRG pricing methodology; required.

You have 1-2 years of experience in inpatient clinical coding; preferred.

You have Medicare or Medicare Advantage payment integrity or claims operations experience; preferred.

You are technologically savvy with strong computer skills in Excel and PowerPoint.

You are able to demonstrate success within a structured clinical review environment.

You understand the importance of maintaining regulatory compliance in all coding practices.

You possess strong analytical and problem-solving skills related to payment integrity and coding accuracy.

You have the ability to communicate effectively with clinical and non-clinical stakeholders.

You have the ability to work independently and as part of a collaborative team.

You have a strong attention to detail to ensure accurate identification of coding issues.

You have a demonstrated commitment to ethical standards and data confidentiality.

You have the ability to manage multiple priorities in a fast-paced remote environment.

You have reliable access to technology required to perform remote work duties.

Nice to have

You have 1-2 years of inpatient clinical coding experience.

You have Medicare or Medicare Advantage payment integrity or claims operations experience.

Practical notes

This is a remote role based in the United States with no specified hours, travel, visa, or application deadlines in the source material.