Clover is reinventing health insurance by working to keep people healthier.
The Payment Integrity team is a group of innovative thinkers sitting at the intersection of Clover's provider Network, Claims, & 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 Senior Associate for Payment Integrity at Clover Health, you will be responsible for the development, implementation, & 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 & compliance with Clover's internal policies & procedures.
As a Senior Associate you will:
- Oversee day-to-day operations of Clover's cost containment vendors. Serve as point-of-contact between external vendors & various operations teams within Clover. Monitor, evaluate, & report on overpayment inventory to ensure for findings accuracy, adherence to SLA's, & compliance with Clover P&P's. Review & approve all vendor overpayment concepts prior to pursuit.
- Identify, research, & resolve complex & escalated claim payment issues originating from vendor findings. Independently resolve escalations without management involvement.
- Establish & lead ongoing vendor reviews to monitor vendor performance against savings targets, & to ensure vendors implement corrective actions & address performance deficiencies as needed.
- Present information such as strategic concepts, planning data, medical expense savings, vendor reimbursement rates, vendor/concept performance metrics, & impact assessments to both internal & 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, & want your work to make a difference in our members' lives.
- You are a team player. You enjoy partnering with others, & want to work collaboratively to find new solutions.
- You are a strong communicator. You have strong verbal & written communication skills that foster trust, knowledge sharing, & 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, & 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 & 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 & 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 & ICD 9/10) & 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 & regulations .
- You have experience working in 'production' environments (vendor or payer) with an emphasis on hitting financial targets (preferred, not required).
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest & 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 & analytics to empower our clinical staff to intervene & provide personalized care to the people who need it most.
We always put our members first, & our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate & mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.
From Clovers inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer & our employees are people with different strengths, experiences & backgrounds, who share a passion for improving people's lives. Diversity not only includes race & gender identity, but also age, disability status, veteran status, sexual orientation, religion & many other parts of ones identity. All of our employees points of view are key to our success, & inclusion is everyone's responsibility.