Senior Claims Researcher

At Clover Health, we’re focused on improving the health of our members by leveraging technology and data-driven insights to provide personalized, high-quality care. As a Medicare Advantage plan, we aim to empower our members by helping them navigate the complexities of healthcare and live healthier lives. We are passionate about making healthcare easier, more affordable, and more accessible for everyone.

We are looking for a highly analytical Senior Claims Researcher to join our Claims Excellence team. Reporting directly to the Director, Claim Payment Accuracy, you will be a key individual contributor responsible for executing the high-level technical audits and testing that ensure our claims are paid correctly the first time.

You are not just a claims processor; you are a "claims detective" who enjoys digging into complex data to find the "why" behind payment variances. In this role, you will perform deep-dive research and quality audits across our adjudication ecosystem, focusing on the intersection of provider contracts, benefit design, and system configuration. While you will not be responsible for the development or maintenance of clinical and reimbursement policies, you will be the primary engine that tests our payment accuracy against them.

• Technical Quality Auditing: Execute the monthly audit plan as designed by the Director, performing detailed reviews of claims to ensure they align with provider contracts, benefit rules, and pricing guidelines.
• Root Cause Research: Go beyond identifying errors; perform deep-dive research into HealthEdge HRP and Source to determine if a variance was caused by configuration logic, manual intervention, or policy misinterpretation.
• Data-Driven Reporting: Compile and present audit findings that highlight trends and "enterprise risk" areas, categorizing errors to provide the Director with actionable insights for executive-level reporting.
• AI-Enabled Oversight: Support the implementation of AI and Machine Learning auditing tools by providing the "human-in-the-loop" feedback necessary to train and refine automated accuracy models.
• BPaaS & Configuration Collaboration: Partner closely with our external BPaaS stakeholders and internal Configuration teams to communicate audit findings, utilizing JIRA to track the lifecycle of an error from identification to systemic resolution.
• Strategic Testing: Act as the final safeguard for Clover’s adjudication accuracy, ensuring that the system's "real-world" output matches the contractual and benefit intent.

• By the end of your initial 90-day period: You will have mastered the nuances of Clover’s HealthEdge HRP and Source environments and will be actively executing the monthly audit cycle, performing both random and risk-based judgmental audits to ensure baseline payment accuracy.
• By 6 months: You will be recognized as the "SME of Record" for identifying systemic payment trends across pricing and benefits. You will also be actively leveraging AI tools like Claude, Gemini, and ChatGPT to build out ongoing monitoring and oversight trends that identify high-impact risks to support judgmental sampling and targeted audits.
• Continued success: You will be at the forefront of "Audit 2.0," utilizing AI-forward strategies to increase the scope and speed of your research. Your work will directly contribute to Clover’s commitment to achieving top-tier payment precision and the reduction of billing friction for our members and provider partners.

• You have 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication.
• You are a certified expert; a current coding certification is required (CPC, CCS, COC, or CIC).
• You possess deep technical proficiency in HealthEdge HRP and Source.
• You have a "researcher's mindset"—you are naturally curious, detail-oriented, and persistent in finding the root cause of a technical problem.
• You are extremely AI-forward and excited to use technology and LLMs (Claude, Gemini, ChatGPT) to move away from manual, spreadsheet-based auditing.
• You are a strong communicator who can translate complex technical findings into clear, actionable reports for leadership.