Clover is reinventing health insurance by working to keep people healthier.
The Special Investigation Unit (SIU) is a motivated, collaborative team sitting at the intersection of Compliance, Payment Integrity, & Data Infrastructure. The SIU ensures that Clover monitors, identifies & investigates instances of healthcare fraud, waste & abuse (FWA). Come join us as we discover new opportunities to enhance the fight against FWA!
As the SIU Manager, you will play a critical role ensuring that Clover is able to continue to build & scale a compliant, effective FWA audit program. You will work to ensure quality assurance standards & regulatory policy are reflected in our audit practices. You will be joining a fast-growing & fast-moving startup at the intersection of healthcare & technology, where you will have the opportunity to develop both your policy & operational skills. A successful SIU Manager will have a robust FWA knowledge base & be able to develop, document & execute an effective & efficient FWA audit strategy to identify, audit, track, & report on known or suspected instances of FWA.
As a SIU Manager, you will
- Develop Policies & Procedures to document SIU Operations.
- Lead development & execution of SIU process improvements to improve the effectiveness & efficiency of our SIU audit processes.
- Implement an effective ideation process to identify known or suspected instances of FWA .
- Establish & exceed annual FWA audit goals.
- Manage complex provider conversations around FWA audit findings.
- Prepare response letters to deliver decisions to providers within the regulatory timeframes set forth by the Centers for Medicare & Medicaid Services (CMS).
- Manage overall audit workload to ensure timely & accurate audit results.
- Act as the FWA subject matter expert.
- Work with individual team members on growth & career development.
- Build strong working relationships with both regulatory & law enforcement agencies.
- Communicate effectively while building trust & lasting partnerships both laterally & vertically across multi-discipline teams.
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 strategic prioritizer, and able to identify where & when to focus your energy.
- You have a critical & analytical mindset. You understand how all the components of a process fit together & believe in the value of making data-driven decisions; you continuously monitor the efficacy of your programs through metrics tracking.
- You are passionate about researching complex regulations & putting it to work for the good of others.
- 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 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 have 5+ years of experience in the healthcare FWA space.
- You have 2+ years of experience managing functional teams or projects against broader operational goals.
- You have experience implementing & managing operations & process improvement efforts.
- You have an understanding of compliance payer requirements including Medicare regulations.
- You have knowledge on fraud statutes & regulations.
- You have a Fraud Investigation Certification (CFE, AHFI, etc.) - preferred but 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.