Regional Agency Manager
Western National Insurance
Clinical Coding Manager
Clover Health
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteSalary
💰 $100,000 - $130,000 per year
Job Level
Mid-LevelSenior
Tech Stack
SQL
About the role
- Manage prospective claim review queues related to clinical DRG coding compliance, readmissions programs, and cross-functional high dollar claim review
- Develop and execute strategies and procedures to grow the payment integrity team and drive process improvements
- Ensure payment integrity programs run smoothly and stay compliant with internal and Medicare guidelines
- Prepare provider responses to clearly and accurately deliver review decisions within regulatory timeframes established by CMS
- Identify potential program efficiencies and implement procedural responses
- Analyze existing policies to ensure accuracy and proper execution
- Collaborate with teams across Clover to ensure provider understanding of Payment Integrity recommendations and support those recommendations when necessary
- Act as Subject Matter Expert to counsel team members on clinical coding guidelines and communicate complex concepts to stakeholders including senior leadership
- Train team members to take on additional responsibilities and help prioritize work functions
- Research and respond to external auditor concerns regarding completeness and accuracy of data creation and integration
- Incorporate cross-functional perspectives and business needs in solving complex problems
- Communicate effectively internally and externally to ensure accurate claims adjudication and proper provider notification
- Oversee prepay clinical review workflows and contribute to DRG validation, avoidable readmission reviews, length-of-stay reviews, and provider appeals as a subject matter expert
Requirements
- CCS or CIC certification (required)
- Current or previous nursing/firsthand clinical experience or CDI certification (required)
- 5+ years of experience in Medicare or Medicare Advantage payment integrity or claims operations experience
- Previous experience in the insurance industry
- Deep understanding of CMS rules and regulations
- Strong computer skills in Access, Excel, Visio, and PowerPoint
- Knowledge of statistical methods used in the evaluation of healthcare claims data (a plus)
- SQL (a plus)
- Ability to prepare provider responses within CMS regulatory timeframes
- Familiarity with DRG validation, readmission reviews, and length-of-stay reviews
- Remote work in the USA (job location: Remote - USA)
Benefits
- Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities.
- Performance-based bonus program
- 401k matching
- Regular compensation reviews
- Comprehensive medical, dental, and vision coverage
- No-Meeting Fridays
- Monthly company holidays
- Access to mental health resources
- Generous flexible time-off policy
- Remote-first culture that supports collaboration and flexibility
- Learning programs, mentorship, and professional development funding
- Regular performance feedback and reviews
- 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!
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical DRG codingpayment integrityclaims operationsstatistical methodsSQLprovider responsesDRG validationreadmission reviewslength-of-stay reviewsauditor response
Soft skills
collaborationcommunicationtrainingproblem-solvingleadershipstrategic planningprocess improvementcounselingprioritizationefficiency identification
Certifications
CCSCICCDI certification
