Operations Specialist, Payment Integrity

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 Clovers provider Network Claims and 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 an Operations Specialist for Payment Integrity at Clover Health you will play a key role in supporting multiple cost containment work streams across the Medicare Advantage and Direct Contracting lines of business. You will help drive value for every member by ensuring that Clovers medical claims are paid accurately and recovering overpayments when they are identified.

As an Operations Specialist you will:

• Manage key elements of the recovery workflows and communications to ensure Clover is accurately paying claims and partnering with Providers in an efficient streamlined manner.
• Support the team with daily operational tasks such as triaging and responding to provider disputes and inquiries.
• Work cross-functionally across Payment Integrity Claims Provider Solutions and other stakeholders to drive financial savings and maintain strong provider relationships.
• Incorporate cross-functional perspectives and business needs in solving complex problems.
• Support subject matter experts to improve team efficiency and maximize team ROI.
• Help shape the department by contributing to process documentation and training (e.g. meeting minutes workflows and standing operating procedures).

Success in this role looks like:

• By the end of your initial 90-day period you will have demonstrated a strong understanding of our payment integrity workflow and are able to effectively navigate throughout the various Clover systems.
• By 6 months you will be working autonomously to triage and prioritize incoming inquiries and communications.
• Continued success in this position anchors in on developing a deep understanding of the workflows that support our payment integrity review life cycle while maintaining regulatory compliance standards.

You should get in touch if:

• You have 1 year of experience in healthcare preferably in process improvement operations and/or analytics.
• You are able to execute on daily tasks and priorities effectively communicating progress to leadership.
• You have strong project management or administrative skills and can multi-task while being highly organized and thorough.
• You are able to regularly identify opportunities to implement efficient process/operational improvements.
• You have a working knowledge of Excel and are able to produce basic reports when requested.
• You have a working understanding of healthcare topics pertaining to Network such as physician reimbursement models data sharing in provider partnerships and PCP engagement.

Benefits Overview:

• 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!

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 weve 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 Clovers 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 perspectives opinions and backgrounds who share a passion for improving peoples lives. Diversity not only includes race and gender identity but also age disability status veteran status sexual orientation religion and many other parts of ones identity. All of our employees points of view are key to our success and inclusion is everyones responsibility.

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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 anE-Verify company.

A reasonable estimate of the base salary range for this role is $68000 to $83000. Final pay is based on several factors including but not limited to internal equity market data and the applicants education work experience certifications etc.

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