Operations Lead, Claims at Clover Health
Nashville, TN, US

Clover is reinventing health insurance by working to keep people healthier.

The Claims team is a group of dedicated, hard-working, enthusiastic individuals working at the heart of insurance operations. This team maintains the business function of any claims related activities, including claims monitoring, payment disputes, escalated provider inquiries, and system claims system configuration.

We are looking to hire an Operations Lead to serve as a key member of the Claims team. In this role you will supervise a group of Claims Analysts and work with both departmental and organizational business partners to resolve service barriers, develop solutions to improve effectiveness and identify improvement initiatives to increase service levels to Clover’s members and providers. Reporting to the Sr. Director of Claims, you will play a crucial role in executing Clover’s mission by bringing your Medicare Advantage subject matter expertise to our growing team.

As an Operations Lead, you will:

  • Provide daily supervision and leadership to the Claims Team in order to consistently meet established productivity and adherence to quality standards.
  • Assist with the development of workflows, policies and procedures for the claims department; confirm that all desk-level procedures are aligned with the plan and adhere to CMS and other regulatory requirements.
  • Perform business analysis and research of identified process and software gaps or inefficiencies.
  • Work with partners in system configuration and other related functions to ensure a high level of service.
  • Assist with disputes, reconciliations, and team projects.
  • Handle escalated claims-related complaints from internal and external business partners.
  • Actively collaborate with management and staff to ensure that “best practices” are followed and continually seek efficient and innovative processes, technologies and approaches to optimize use of resources and enhance operations.
  • Maintain a working knowledge of all CMS Medicare Advantage claims processing guidelines, processes, and protocols, including program audit requirements.
  • Perform other duties and projects as assigned.

You will love this job if:

  • You are a people-oriented leader with a track record of mentoring, developing, and motivating peers and direct reports.
  • You are a true collaborator and believe in working cohesively with other departments to move things forward.
  • You feel a deep sense of ownership and accountability for maintaining the health of your team and business impact and you drive responses and change toward a meaningful team direction.
  • 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 should get in touch if:

  • You have 5-8 years experience in supporting Medicare Advantage claims processing and understanding of claims system configuration functions.
  • You have deep knowledge of Medicare Advantage benefit design, benefit structures, medical policies, and pay policies and their impact on claims/benefit configuration and claims processing.
  • You have prior lead or supervisory experience in a claims department.
  • You have previous experience with claims operating systems such as Facets, QNXT, Health Edge, or Amethyst.
  • You have expert knowledge of medical terminology, ICD-10, and CPT coding required.
  • You are a certified coder (preferred but not required).

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.

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 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.