DRG Validation Auditor

The role

You will review inpatient claims for DRG-related errors and overpayments, working with clinical, claims and payment integrity teams. You will also talk with physicians to check the clinical reasons for billed procedures.

What you will do

• Review claims for DRG-related issues before and after payment.
• Identify overpayments on inpatient services and ensure accurate payments.
• Take part in discussions with MDs to verify the clinical rationale for billed procedures.
• Communicate with internal teams and external providers to ensure accurate claims and proper provider notification.
• Build trusted working relationships across multi-discipline teams.

Required qualifications

• CCS or CIC certification.
• Knowledge of DRG pricing methodology.
• At least 1 year of direct inpatient clinical coding experience.
• Strong computer skills in Excel and PowerPoint.
• Effective communication skills.

Nice to have

• Medicare or Medicare Advantage payment integrity or claims operations experience.

Benefits

• Competitive base salary and equity opportunities.
• Performance-based bonus program.
• 401k matching and regular compensation reviews.
• Medical, dental and vision coverage.
• No-Meeting Fridays and monthly company holidays.
• Access to mental health resources.
• Generous flexible time-off policy.
• Learning programs, mentorship and professional development funding.
• Employee Stock Purchase Plan (ESPP).
• Reimbursement for office setup expenses.
• Monthly cell phone and internet stipend.
• Paid parental leave for all new parents.

Before you apply

• The employer is an E-Verify company.
• Applicants with arrest and conviction records will be considered, per the San Francisco Fair Chance Ordinance.

About the company

Clover is reinventing health insurance by combining data with human empathy to keep members healthier. The company builds custom software and analytics so clinical staff can give personalized care.