The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, and Tech teams. The Payment Integrity team ensures that Clover pays claims in an accurate manner, with a particular focus on reducing inappropriate medical spend.
As a Vendor Manager for Payment Integrity at Clover Health, you will be responsible for the development, implementation, and ongoing management of multiple cost containment vendors. You will be responsible for maximizing each vendor relationship to optimize financial savings, while also ensuring for adherence to SLA's and compliance with Clover's internal policies and procedures.
As a Vendor Manager you will:
- Oversee day-to-day operations of Clover's cost containment vendors. Serve as point-of-contact between external vendors and various operations teams within Clover. Monitor, evaluate, and report on overpayment inventory to ensure for findings accuracy, adherence to SLA's, and compliance with Clover P&P's. Review and approve all vendor overpayment concepts prior to pursuit.
- Identify, research, and resolve complex and escalated claim payment issues originating from vendor findings. Independently resolve escalations without management involvement.
- Establish and lead ongoing vendor reviews to monitor vendor performance against savings targets, and to ensure vendors implement corrective actions and address performance deficiencies as needed.
- Present information such as strategic concepts, planning data, medical expense savings, vendor reimbursement rates, vendor/concept performance metrics, and impact assessments to both internal and external audiences at all levels, including senior-level leadership.
- Handle other duties as assigned.
You will love this job if:
- You want to make an impact. You thrive off of helping others, and want your work to make a difference in our members' lives.
- You are a team player. You enjoy partnering with others, and want to work collaboratively to find new solutions.
- You are a strong communicator. You have strong verbal and written communication skills that foster trust, knowledge sharing, and progress.
- You are detail-oriented. You pay attention to the small things, while understanding how they fit into the bigger picture.
- You are motivated to learn. There is no shortage of technical, clinical, and operational skills to learn at Clover.
- You are curious. You like to do research when you don't know an answer. You ask the hard questions and you don't sweep problems under the rug.
You should get in touch if:
- You hold a BA/BS degree or equivalent experience along with 5+ years of experience in the health care industry, with deep exposure to Payment Integrity and Medicare Advantage.
- You have 5+ years of experience billing, coding, processing, and/or auditing claims along with knowledge of correct coding guidelines (CPT, HCPCS, DRG and ICD 9/10) and reimbursement methodologies (FFS/professional, APC, DRG, etc.). Coding certification through AAPC or AHIMA preferred.
- You are technologically savvy with strong computer skills in Access, Excel, Visio, PowerPoint & entry-level knowledge of SQL. Knowledge of statistical methods used in the evaluation of healthcare claims data preferred.
- You have a working knowledge of CMS rules and regulations .
- You have experience working in 'production' environments (vendor or payer) with an emphasis on hitting financial targets (preferred, not required).