[All remote jobs](https://jobicy.com/jobs.md)[![Clover Health logo](https://jobicy.com/data/server-nyc0409/galaxy/mercury/2025/06/8d4e74b3-221.jpg)](https://jobicy.com/company/clover-health.md)[Clover Health](https://jobicy.com/company/clover-health.md) # Medical Claims Auditor AI Summary Medical Claims Auditor will support Clover Health’s Special Investigations Unit by auditing Medicare-related claims for fraud, waste, abuse, billing, and coding issues. The role conducts prepayment and retrospective reviews, identifies control opportunities, and helps prevent inaccurate provider payments. It requires close collaboration with clinical, claims, data science, and engineering teams to validate AI-flagged claims and improve machine-learning workflows. Candidates need at least three years of coding and auditing experience, CPC certification, and strong knowledge of CMS correct-coding rules. The position is a remote, US-based full-time role in a fast-paced health-insurance technology environment.[Apply for this job](#job-application)[View company](https://jobicy.com/company/clover-health.md)ShareRemote from[USA](https://jobicy.com/job-region/usa.md)SalaryUSD 92,300–120k / yrDepartment[Healthcare & Medical](https://jobicy.com/categories/healthcare.md)EmploymentFull TimeExperienceSeniorPublished4 Nov 2026Apply before4 Dec 2026Listing views19Application actions1Application toolkit ## Make your next move. Prepare your resume, explore your fit, and draft a cover letter for this opportunity. Opportunity details ## About this role. The Special Investigation Unit (SIU) is a motivated, collaborative team sitting at the intersection of Compliance, Payment Integrity, and Data Infrastructure. The SIU ensures that Clover monitors, identifies, and investigates instances of healthcare fraud, waste and abuse (FWA). Come join us as we discover new opportunities to enhance the fight against FWA! As a Medical Claims Auditor within our Special Investigations Unit, you will play a critical role in ensuring that Clover is able to continue to build and scale a compliant, effective FWA audit program. You will be joining a fast-growing and fast-moving startup at the intersection of healthcare and technology, where you will have the opportunity to develop both your policy and operational skills. A successful Medical Claims Auditor will have a broad coding knowledge base, including but not limited to: DME, Outpatient, ASC and Physician correct coding. This position will focus specifically on Medicare coding policies. As a Medical Claims Auditor, you will: * Partner with Clinical, Claims, and SIU peers to review claims for billing and coding-related issues on both a prepayment and retrospective basis to prevent inaccurate payments to providers and disrupt FWA before funds leave the door. * Leverage internal AI tools and predictive models to proactively identify anomalous billing patterns, emerging trends, and new opportunities for targeted prepayment audits. * Collaborate directly with our Data Science and Engineering teams to validate AI-flagged claims in the prepayment queue, providing expert coding feedback to continuously train and refine our machine learning models. * Identify control opportunities to mitigate FWA, focusing heavily on implementing systemic prepayment edits. * Identify possible audit opportunities through AI-assisted data analysis and manual case identification. * Support annual FWA audit goals by prioritizing high-value reviews. * Support provider conversations around FWA audit findings, translating complex data, AI insights, and prepayment denials into clear, actionable compliance feedback. * Manage overall audit workload to ensure timely and accurate audit results within strict prepayment turnaround times. * Work closely with senior team members and management on targeted projects and initiatives. * Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams. Success in this role looks like: * By the end of your initial 90 day period, you will have demonstrated a strong understanding of our review process and are able to effectively navigate through the various Clover systems. * By 6 months, you will be working autonomously on provider reviews and supporting further case/opportunity identification. * Continued success in this position anchors in on developing a deep understanding of the workflows that support our SIU cases and reviews while maintaining regulatory compliance standards. You should get in touch if: * You have 3+ years of coding and auditing experience, experience with CMS regulations preferred. * You are a Certified Professional Coder (CPC). * You have a strong knowledge of the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI. * You have experience working in a technology environment including claims systems, workflow management tools, Microsoft Office or Google Suite. * You have prior experience working in health insurance; Medicare Advantage is a plus. Benefits Overview: * Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions. * Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare. * Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. * Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews. Additional Perks: * Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities * Reimbursement for office setup expenses * Monthly cell phone & internet stipend * Remote-first culture, enabling collaboration with global teams * Paid parental leave for all new parents * And much more! 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, perspectives, opinions, 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. #LI-REMOTE 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](https://e-verify.uscis.gov/esp/media/resourcesContents/E-Verify_Participation_Poster.pdf) company. Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc. A reasonable estimate of the base salary range for this role is: $92,300—$120,000 USD Show more [Apply now >](https://jobicy.com/jobs/159017-medical-claims-auditor.md) * ![Upload CV](data:image/svg+xml;base64,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) ### Upload your resume now To unlock remote work opportunities and be discovered by global employers. This job listing has been manually reviewed by the Jobicy Trust & Safety Team for compliance with our posting guidelines, including verification of the company's legitimacy, accuracy of job details, clarity of remote work policy, and absence of misleading or fraudulent content. ## Role DNA A quick view of the complexity, pace, ownership and collaboration implied by the job description. ### Job Complexity 4/5EasyHard ### Pace & Pressure 4/5RelaxedFast-paced ### Autonomy Level 4/5GuidedFull ownership ### Communication Load 4/5IndependentCollaborative AI insightРабота требует специализированной экспертизы в Medicare-кодировании, CMS/CCI правилах и аудите страховых claims, а также точных решений с финансовыми и комплаенс-последствиями. Темп повышают строгие сроки prepayment-проверок и необходимость самостоятельно вести provider reviews после адаптации. ## Salary analysis Estimated compensation compared with the broader US market for similar roles. Estimated job median (per year)Highly competitive$106,150US market range (per year)$85k–$125k0$137.50k AI insightThe yearly pay period is inferred from the job context; it was not explicitly stated by the employer. Работодатель указывает базовый диапазон $92,300–$120,000 USD. Период оплаты прямо не указан, поэтому для штатной профессиональной роли в США он логически интерпретирован как годовой. Оценочный рыночный диапазон для медицинского аудитора страховых claims с CPC и Medicare-экспертизой составляет $85,000–$125,000 USD в год. ## Core skills Skills and capabilities most closely associated with this opportunity. [Medical claims auditing](https://jobicy.com/jobs?search_keywords=Medical%20claims%20auditing.md)[Medicare coding](https://jobicy.com/jobs?search_keywords=Medicare%20coding.md)[CPC certification](https://jobicy.com/jobs?search_keywords=CPC%20certification.md)[CMS regulations](https://jobicy.com/jobs?search_keywords=CMS%20regulations.md)[CCI edits](https://jobicy.com/jobs?search_keywords=CCI%20edits.md)[Fraud waste and abuse detection](https://jobicy.com/jobs?search_keywords=Fraud%20waste%20and%20abuse%20detection.md)[Payment integrity](https://jobicy.com/jobs?search_keywords=Payment%20integrity.md)[Prepayment audits](https://jobicy.com/jobs?search_keywords=Prepayment%20audits.md)[Retrospective audits](https://jobicy.com/jobs?search_keywords=Retrospective%20audits.md)[Healthcare compliance](https://jobicy.com/jobs?search_keywords=Healthcare%20compliance.md)[Provider communication](https://jobicy.com/jobs?search_keywords=Provider%20communication.md)[Claims systems](https://jobicy.com/jobs?search_keywords=Claims%20systems.md)[AI-assisted analytics](https://jobicy.com/jobs?search_keywords=AI-assisted%20analytics.md)[Microsoft Office](https://jobicy.com/jobs?search_keywords=Microsoft%20Office.md)[Google Workspace](https://jobicy.com/jobs?search_keywords=Google%20Workspace.md) Sample interview questionsHow do you approach a Medicare claim audit when you suspect a coding or billing error?I first confirm the relevant documentation, code set, payer policy, and CMS or CCI guidance. I compare the submitted claim against medical necessity, modifier, bundling, and documentation requirements, then document the rationale and recommended action clearly for consistency and auditability. Describe your experience applying National Correct Coding Initiative edits. I use CCI edits to evaluate whether procedure codes can be billed together and whether a modifier is appropriately supported. I review the clinical documentation and policy exceptions before recommending a denial, correction, or payment decision. How would you validate a claim flagged by an AI model for anomalous billing? I would treat the model flag as a prioritization signal rather than a final decision. I would review claim history, coding patterns, provider context, supporting records, and applicable policy rules, then provide structured feedback on whether the alert was valid and why. How do you maintain quality while meeting strict prepayment turnaround times? I triage claims by risk, financial impact, and due date, use consistent review checklists, and document decisions as I work. For ambiguous cases, I escalate early with a concise summary of the issue so that quality is not sacrificed for speed. How would you communicate a prepayment denial or audit finding to a provider? I would explain the decision in objective, plain language tied to the relevant coding or policy requirement. I would identify the affected service or code, describe the documentation or billing issue, and outline any appropriate corrective action or appeal pathway. Next step ## Apply now. Follow the employer’s application method and review Jobicy’s safety guidance before sharing personal information. 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