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Manager, Payment Integrity

Clover Health

Remote / United States of America
  • Job Type: Full-Time
  • Function: Accounting/Finance
  • Industry: Digital Health
  • Post Date: 11/22/2022
  • Website: cloverhealth.com
  • Company Address: P.O. Box 471, Jersey City, NJ 07303

About Clover Health

Clover Health is a data driven health insurance startup driving to improve the overall state of healthcare in America. We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road.

Job Description

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

The Payment Integrity team is a motivated, collaborative team sitting at the intersection of Clover's provider relationship operations, data infrastructure, and software. The Payment Integrity team ensures that Clover pays claims in a fair, transparent, compliant, and medically justified manner. Come join us as we discover new opportunities to improve the financial health of Clover while strengthening provider relationships and building a better healthcare system.

As a Manager within our Payment Integrity team, you will play a critical role ensuring that Clover is able to continue to build and scale a compliant, efficient and profitable program. You will work to ensure quality assurance standards and regulatory policy are reflected in claims processing 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 Manager will have a deep understanding of Medicare payment methodologies and experience managing highly regulated processes.


As a Manager, Payment Integrity, you will:

  • Oversee the entire prepayment review process including maintenance of claim selections, clinical and coding review, provider communication, and dispute resolution.
  • Ensure success of all components of the prepayment review programs and monitor progress to team level goals, providing succinct reporting to leadership.
  • Drive consistent ideation of new audit concepts in both the prepayment and postpayment space to generate incremental year-over-year savings and significant contributions toward company level goals.
  • Manage quality of all internally developed prepayment reviews through quality assurance review and partnership with Ideation Associate to maintain accurate reporting.
  • Act as a subject matter expert - digest complex Medicare concepts and regulations and communicate them effectively to different stakeholders, including senior leadership.
  • Research and respond to external auditor concerns/questions regarding the completeness and accuracy of data creation and integration.
  • Work closely with data scientists, engineers and operational teams to create sustainable and scalable solutions.
  • Communicate effectively while building trust and lasting partnerships both laterally and vertically across multi-discipline teams.

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 passionate about researching complex regulations and putting it to work for the good of others.
  • 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 have 5+ years of experience in Payment Integrity auditing and recovery.
  • Two years of Medicare payment methodologies and the National Rules of Correct Codification defined by CMS in the Manual of CCI and the tables of CCI.
  • Experience managing complex processes in a technical environment and synthesizing performance for senior leadership. 
  • You have claims or revenue cycle accounting experience - preferred but not required.

 

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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.


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.

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