Senior Investigator

Описание вакансии

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 the Senior Investigator, you will play a critical role ensuring that Clover is able to continue to build and scale a compliant, effective FWA audit program. You will work to ensure quality assurance standards and regulatory policy are reflected in our audit practices. 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 Senior Investigator will have a robust FWA knowledge base and be able to develop, document and execute an effective and efficient FWA audit strategy to identify, audit, track, and report on known or suspected instances of FWA.

As a Senior Investigator, you will:

• Lead development and execution of SIU process improvements to improve the effectiveness and efficiency of our SIU audit processes
• Identify control opportunities to mitigate FWA
• Identify possible audit opportunities
• Implement an effective audit strategy to investigate known or suspected instances of FWA
• Support annual FWA audit goals
• Support complex provider conversations around FWA audit findings
• Prepare response letters to deliver decisions to providers within the regulatory timeframes set forth by the Centers for Medicare & Medicaid Services (CMS).
• Manage overall audit workload to ensure timely and accurate audit results
• Act as a FWA subject matter expert
• Mentor other team members on audit strategies
• Build strong working relationships with both regulatory and law enforcement agencies, and
• 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 SIU case flow and are able to effectively navigate through the various Clover systems.
• By 6 months, you will be working autonomously on cases and provider reviews.
• 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 5+ years of experience in the healthcare FWA space.
• You have experience identifying operations and process improvement efforts.
• You have an understanding of compliance &  payer requirements including Medicare regulations.
• You have knowledge on fraud statutes and regulations
• You have a Fraud Investigation Certification (CFE, AHFI, etc.) - preferred but not required.

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.

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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.

A reasonable estimate of the base salary range for this role is $104,000 to $127,000. 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.

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