Director, Claim Payment Accuracy

🕒 May 15

🇺🇸 United States – Remote

💵 $150k - $195k / year

⏰ Full Time

🔴 Lead

👔 Director

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Clover Health (Nasdaq: CLOV) is a physician enablement company focused on seniors who have historically lacked access to affordable, high-quality healthcareWe aim to provide great care, in a sustainable way, by having a business model built around improving medical outcomes while lowering avoidable costs. We do this while taking a holistic approach to understanding the health needs and social risk factors of those under our care. This strategy is underpinned by our proprietary software platform, the Clover Assistant, which is designed to aggregate patient data from across the health ecosystem to support clinical decision-making by presenting physicians and other providers with real-time, personalized recommendations at the point of care.Making care more accessible is at the heart of our business, and we believe patients should have the freedom to choose their doctors. We offer affordable Medicare Advantage plans with extensive benefits, provide primary care physicians with the Clover Assistant, and also make comprehensive home-based care available via the Clover Home Care program.With our corporate headquarters in Nashville, Clover’s workforce is distributed around the U.S. and also includes a team of world-class technologists based in Hong Kong. We manage care for Medicare Advantage members in Alabama, Arizona, Georgia, Mississippi, New Jersey, Pennsylvania, South Carolina, Tennessee, and Texas.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.If you’re a passionate person and interested in changing healthcare for the better, then Clover Health may just be the place for you.

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

• 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!