Operations Associate Payment Integrity

Clover is reinventing health insurance by working to keep people healthier.

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America's seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member's complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most.

The Payment Integrity team is a motivated, collaborative team sitting at the intersection of Clover's provider relationship operations, data infrastructure, and software. The Payment Integrity team ensures that Clover pays claims in a fair, transparent, compliant, and medically justified manner. Come join us as we discover new opportunities to improve the financial health of Clover while strengthening provider relationships and building a better healthcare system.

As an Operations Associate for Payment Integrity at Clover Health, you will play a key role in facilitating the underlying processes that support various cost containment work streams. You will help drive value for every member by ensuring that Clover's medical claims are paid accurately and be responsible for facilitating recoveries on a growing membership base while supporting coordination between internal and external stakeholders.

As an Operations Associate, Payment Integrity, you will:

• Execute Claim Reprocessing Cycles: Facilitate the aggregation of high-volume claim batches for reprocessing. Utilize advanced data management and spreadsheeting techniques to merge, review, and validate cycles of claim adjustments, ensuring precision prior to final submission.
• Perform Reprocessing Reconciliations: Facilitate backend controls to audit the accuracy of batch-reprocessed claims. Conduct comprehensive reconciliations to ensure that all expected adjustments are accurate and complete.
• Develop and Maintain Claim Processing Workflows: Collaborate with cross-functional teams to design, implement, and maintain claim processing workflows that ensure compliance with regulatory requirements and internal policies.
• Provide Exceptional Customer Service: Respond to inquiries from internal stakeholders, including claims processors, and external stakeholders, such as providers and members, in a timely and professional manner.
• Participate in Continuous Improvement Initiatives: Contribute to process improvement initiatives by identifying areas for improvement, proposing solutions, and implementing changes to enhance efficiency, accuracy, and compliance.
• Stay Up-to-Date with Industry Developments: Stay current with industry trends, regulatory changes, and best practices to ensure that Clover's payment integrity processes remain compliant and effective.
• Collaborate with Cross-Functional Teams: Work closely with other teams, including claims processing, provider relationship management, and data analytics, to ensure seamless integration and effective communication.
• Ensure Compliance with Regulatory Requirements: Stay informed about regulatory changes and ensure that Clover's payment integrity processes comply with relevant laws, regulations, and industry standards.
• Develop and Maintain Relationships with Stakeholders: Build and maintain strong relationships with internal stakeholders, including claims processors, and external stakeholders, such as providers and members, to ensure effective communication and collaboration.
• Perform Other Duties as Assigned: Perform other duties as assigned by management, including special projects, ad-hoc requests, and other tasks that support the Payment Integrity team's goals and objectives.

Come join us as we discover new opportunities to improve the financial health of Clover while strengthening provider relationships and building a better healthcare system.