Payment Integrity Analyst

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most. Clover’s Payment Integrity team is responsible for ensuring claims are paid accurately, consistently, and in accordance with applicable requirements. We’re looking for a Payment Integrity Analyst who brings strong Medicare Advantage claims and reimbursement knowledge, investigative judgment, and the ability to translate claims data into defensible findings. In this role, you’ll investigate potential payment inaccuracies, evaluate claims populations identified through SQL analysis, and determine whether the evidence supports a payment issue or a correctly adjudicated outcome. You’ll research applicable requirements, work through claim histories and exceptions, and help turn validated findings into actionable recommendations and repeatable audits. You’ll work closely with the Senior Manager, who will lead complex SQL development, investigation priorities, and validation methodology. You should be comfortable independently running and adapting existing queries, using AI tools thoughtfully, and taking ownership of assigned investigations from initial review through a documented recommendation. As a Payment Integrity Analyst, you will: • Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge to interpret claims data and explain payment outcomes. • Review claims populations identified through SQL analysis and distinguish supported payment discrepancies from valid exceptions, data issues, and correctly adjudicated claims. • Research applicable CMS/NCCI and other coding guidance, provider contract terms, benefit documents, and 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 to understand what occurred and assess the expected payment outcome. • Independently run SQL queries and make targeted changes to dates, filters, and claim selections. • Actively seek evidence that could disprove a suspected issue, including correctly paid comparison claims, exceptions, and alternative explanations. • Document the applicable sources, validation steps, exclusions, supported payment impact, and unresolved questions clearly enough for another reviewer to reproduce the conclusion. • Use approved AI tools to support research, query interpretation, and documentation while verifying sources, factual claims, and analytical outputs. • Review and audit outputs from audit tools, identifying false positives and refining rules to improve precision. • Prepare findings for review and support downstream recovery evaluation, operational resolution, and Compliance/Legal review as needed. • Contribute to recurring audits, monitor previously validated issues, and recommend improvements to investigation and testing processes. Success in this role looks like: • Within the first 90 days , you’ve developed a working understanding of Clover’s claims data, payment integrity workflows, and validation approach. You’re independently running and making basic adaptations to existing queries, completing assigned claim reviews, and documenting findings and open questions clearly. • Within six months , you’re taking ownership of defined investigations with limited day-to-day direction, identifying exceptions and alternative explanations, and preparing source-supported recommendations for review. You’re also contributing to recurring audits and helping improve the team’s testing and documentation practices. • Over time , your work helps the team identify and validate payment inaccuracies more efficiently, reduce false positives, and translate supported findings into payment corrections and sustainable controls. You should get in touch if: • You typically bring 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. • You have strong practical knowledge of Medicare Advantage claims adjudication and reimbursement, including how benefit provisions, provider contracts, payment policies, and configuration can affect outcomes. • You can investigate payment discrepancies, test competing explanations, recognize exceptions, and distinguish a suspected issue from a supported finding. • You can independently work through defined investigations, identify missing information, and escalate complex or unresolved questions with a clear explanation of the evidence needed. • You have practical SQL proficiency and can navigate large relational database environments, recognizing unexpected duplication, exclusions, or changes in results. • You have strong Excel skills and experience reviewing, filtering, comparing, and reconciling claims-level datasets. • You have meaningful hands-on experience using AI tools in analytical, research, or claims-related work and exercise sound judgment about verification and appropriate data handling. • You communicate clearly in writing and verbally, and can explain complex findings to technical and operational partners. • You bring strong attention to detail and can manage multiple investigations while maintaining organized, traceable documentation. We’d be especially interested if: • You have supported overpayment investigations, payment corrections, or recovery review. • You have tested claims payment rules or investigated configuration-related d