Director, Claim Payment Accuracy

🕒 Maio 15

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $150.000 - $195.000 / ano

⏰ Tempo Integral

🔴 Especialista

👔 Diretor

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Clover Health

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

🏥 Saúde

🛡️ Seguros

🤖 Inteligência Artificial

Healthcare • Insurance • Artificial Intelligence

A Clover Health (Nasdaq: CLOV) é uma empresa de capacitação de médicos focada em idosos que historicamente tiveram dificuldade de acesso a um sistema de saúde de alta qualidade e a preços acessíveis. Nosso objetivo é oferecer um atendimento excelente, de forma sustentável, com um modelo de negócios voltado para melhorar os resultados médicos, reduzindo custos evitáveis. Fazemos isso adotando uma abordagem holística para entender as necessidades de saúde e os fatores de risco social dos que estão sob nosso cuidado. Essa estratégia é sustentada pela nossa plataforma de software proprietária, o Clover Assistant, projetada para agregar dados de pacientes de todo o ecossistema de saúde para apoiar a tomada de decisões clínicas, apresentando aos médicos e outros prestadores recomendações personalizadas em tempo real no ponto de atendimento. Tornar o atendimento mais acessível está no coração do nosso negócio, e acreditamos que os pacientes devem ter a liberdade de escolher seus médicos. Oferecemos planos acessíveis do Medicare Advantage com amplos benefícios, fornecemos aos médicos de atenção primária o Clover Assistant e também disponibilizamos um atendimento abrangente em casa através do programa Clover Home Care. Com a nossa sede corporativa em Nashville, a força de trabalho da Clover está distribuída por todo os EUA e também inclui uma equipe de tecnólogos de classe mundial sediada em Hong Kong. Gerenciamos o cuidado para membros do Medicare Advantage no Alabama, Arizona, Geórgia, Mississippi, Nova Jersey, Pensilvânia, Carolina do Sul, Tennessee e Texas. Estamos contratando engenheiros de software, cientistas de dados, designers e profissionais de produto que possam nos ajudar a entender o bem-estar dos nossos membros e mantê-los longe de quaisquer riscos de saúde no futuro. Se você é uma pessoa apaixonada e interessada em mudar o sistema de saúde para melhor, então a Clover Health pode ser o lugar certo para você.

Descrição

• Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations. • Design and oversee a robust, multi-layered audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms. Ensure that all findings are fed into a continuous improvement loop to enhance systemic accuracy. • Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation. You will independently utilize advanced LLMs (such as Claude, Gemini, and ChatGPT) to analyze oversight trends and develop data-driven criteria for judgmental sampling and targeted audits. • Serve as the lead for global payment accuracy oversight regarding our external BPaaS partner, holding the vendor to world-class standards through global accuracy reviews and data-driven performance monitoring. • Act as the strategic bridge between Clinical, Claims, A&G, UM, Compliance, Quality, and the Configuration team, ensuring that clinical intent, benefit design, and contractual terms are perfectly synchronized in the final payment adjudication.

🎯 Requisitos

• You have 8+ years of leadership experience in healthcare claims, payment accuracy, or policy oversight, with a heavy emphasis on Medicare Advantage. • You are an expert in HealthEdge HRP and Source, with a deep understanding of how these systems interact to drive adjudication accuracy. • You are extremely AI-forward—you are passionate about how emerging technologies and LLMs (Claude, Gemini, ChatGPT) can be applied to drive operational precision in monitoring and research. • You have a proven ability to lead through influence, navigating complex cross-functional relationships to drive systemic change. • You are a Medicare expert with a proven track record of interpreting and operationalizing complex clinical policies, pricing models, and reimbursement guidelines. • You have extensive experience providing oversight for vendor relationships at a strategic level, ensuring partners meet rigorous performance standards. • You are a data-focused leader who builds strategy based on sophisticated dashboards and trend analysis. • You are a master of cross-functional influence, able to align diverse teams around a unified vision of payment excellence. • Preferred qualifications include coding certifications such as CPC, CCS, COC, or CIC.

🏖️ Benefícios

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions. • Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare. • Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. • Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews. • Additional Perks: Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Remote-first culture, enabling collaboration with global teams • Paid parental leave for all new parents • And much more!