Compliance Regulatory Auditor

Clover Health, Remote - USA

Clover is a Medicare Plan done differently.

Clover is reinventing health insurance by working to keep people healthier.

Clover Compliance team is structured to maintain a robust and effective compliance program that aligns with the seven elements described in the Federal Sentencing Guidelines. The Compliance program is designed to prevent, detect and respond to compliance issues and violations of regulatory requirements. You will be working with our Audit team to evaluate compliance risks, perform audits and support internal monitoring.

The Compliance Regulatory Auditor you will be responsible for conducting internal audits of the medical documentation and coding, and will ensure compliance with Federal Regulations. Audits conducted will determine whether coding is supported by the medical record and billed accurately and consistently with medical record documentation.  You have the opportunity to develop formal regulatory audit reports citing findings, observations and provide recommendations supported by federal guidelines or industry best practices.

As a Compliance Regulatory Auditor, you will:

  • Provide formal and informal coding and regulatory education to all coders and clinicians as directed by Federal  requirements and AMA coding directives.
  • Create educational materials such as hand-outs, PowerPoint presentations and other tools to be used during educational sessions.
  • Perform coder audits on a regular basis as defined by compliance requirements, determine when additional education is necessary, and provide training once identified.
  • Support Payment Integrity as needed for investigations requiring code review.
  • Audit clinical documentation and coded data to validate documentation supports services rendered for reimbursement and reporting purposes.
  • Identify coding discrepancies, potential quality of care, and billing issues.
  • Facilitate corrective actions to prevent future errors and deficiencies.
  • Ensure member encounter data (services and disease conditions) is being accurately documented and relevant procedural codes and all relevant diagnosis codes are captured.
  • Prepare written reports of audit results and present this information to management and committees as needed.
  • Serve as resource and subject-matter expert to other coding staff.
  • Assist in the development of educational programs for providers based on audit findings, as well as general education on coding and documentation rules and regulations. 
  • Communicate regularly with internal departments to ensure all necessary information is received on a timely basis at the direction of management.
  • Review and validate responses to audit report to satisfy remediation and resolution.
  • Attend committee meetings as assigned by the Manager/Director. 
  • Provide support to joint projects with other internal audit staff.
  • Communicate findings to Medical Staff and other appropriate personnel, and will provide education on identified issues.

You will love this job if:

  • You are humble and understand that as a subject-matter expert, you are there to serve and support to ensure that team members have the information they need for success.
  • You are a team player. You enjoy partnering with others and want to work collaboratively to find new solutions.
  • You are detail-oriented. You have great follow-up skills and can prioritize and self-manage your work.
  • You are nimble, and comfortable working in a constantly evolving environment. You embrace ambiguity and speed while maintaining a bias towards action.
  • You're also excited by the opportunity to support and bring structure to content that drives the company.

You should get in touch if:

  • You have 5+ years or more experience in Medicare Advantage audits across the operational functions.
  • You graduated with a Bachelor’s degree in healthcare or related field.
  • You have a ICD10-CM and CPC, CCS-P, or RHIT certification (Required).
  • You have experience in CPT-4 and ICD-9/ICD-10 coding and documentation requirements.
  • You have applicable knowledge of Medicare and Medicaid regulations. 
  • Prior experience training/teaching on coding and documentation.
  • You have a high proficiency in the use of various computer systems, including Apple and Microsoft programs.
  • You have superior verbal and written communication skills and possess the ability to successfully present information to a large audience.
  • You have the ability to manage multiple tasks and prioritize work is essential.

#LI-Remote #LI-AS1

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

About Clover Health

Clover Health is a data driven health insurance startup driving to improve the overall state of healthcare in America. We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road. Unlike other health insurance companies also embracing preventive health, Clover’s Medicare is built on technology from the ground-up. Integrating our systems with doctors, clinicians, and nurse practitioners, Clover’s data team helps healthcare professionals in the field intervene directly into patients’ wellness to help them avoid acute health episodes. If you’re a passionate person and interested in changing healthcare for the better, then Clover may just be the place for you.

Clover Health

Want to learn more about Clover Health? Visit Clover Health's website.