AI Analyst, Revenue & Cost Management
Job Description: • Claims Data & Logic SME: Act as the primary domain expert, providing detailed knowledge on the claims life cycle, configuration logic, payment rules, and common points of financial leakage within healthcare operations. • AI Model Support: Collaborate directly with the Lead AI Strategist to translate complex claims and financial scenarios into clear business logic and data features necessary for building predictive models. • Payment Integrity (PI) Validation: Partner directly with Claims Operations and UST to rigorously audit and validate that provider payments adhere to intended rules, supporting the definition of scope for the internal PI engine. • Revenue Optimization Support: Assist in data quality initiatives to enhance risk adjustment and revenue capture, including validating encounter data completeness and NPI fulfillment. • Financial Impact Analysis: Perform detailed, root-cause analysis on payment anomalies, outliers, and emerging claims cost trends flagged by the AI models to confirm financial impact and operational causes. Requirements: • You have 2+ years of experience in a quantitative analysis role focused on healthcare finance, such as claims operations, reimbursement, or payment integrity. • You have foundational experience utilizing large-scale healthcare financial data (claims, encounters, provider networks) in a payer or related vendor setting. • You have proficiency in SQL is required for data querying and manipulation, along with experience using basic statistical software (R, Python, or Excel) for data preparation. • You possess a strong understanding of the healthcare claims life cycle, CPT/HCPCS/ICD-10 coding, and claims adjudication rules (Medicare Advantage experience is a plus). • You are excited by the prospect of directly supporting the development and validation of AI and Machine Learning tools, and translating model outputs into actionable business rules. • You have a Bachelor’s degree in Actuarial Science, Health Economics, Finance, or a related quantitative field is required. Benefits: • 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! Apply tot his job