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Director, Claim Payment Accuracy

1 month, 3 weeks ago
United States
Full-time
Executive
Operations Manager
Data Science and Analytics
LLM
Apply Now
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised
View All Jobs 23

Description

  • Own the development and maintenance of clinical and reimbursement policies in alignment with CMS regulations.
  • Design and oversee a multi-layered audit framework for adjudication output against clinical policies, pricing, benefit rules, and provider contract terms.
  • Create continuous improvement loops that feed audit findings back into systemic accuracy improvements.
  • Lead AI initiatives to automate monitoring of reimbursement policies and contract validation.
  • Use LLM tools such as Claude, Gemini, and ChatGPT to analyze oversight trends and inform sampling and audit criteria.
  • Serve as the strategic lead for payment accuracy oversight of the external BPaaS partner through global reviews and performance monitoring.
  • Act as the bridge between Clinical, Claims, A&G, UM, Compliance, Quality, and Configuration teams to align clinical intent and payment adjudication.
  • Establish and run recurring claims review processes that combine random sampling with targeted, judgmental audits.
  • Monitor enterprise risks and identify leakage, billing friction, and other causes of inaccurate payment outcomes.

Requirements

  • 8+ years of leadership experience in healthcare claims, payment accuracy, or policy oversight, with heavy emphasis on Medicare Advantage.
  • Expert knowledge of HealthEdge HRP and Source and how they support adjudication accuracy.
  • Strong familiarity with CMS regulations, clinical policies, pricing models, and reimbursement guidelines.
  • Demonstrated ability to lead through influence across complex cross-functional relationships.
  • Extensive experience providing strategic oversight of vendor relationships and performance standards.
  • Data-driven leadership experience using dashboards and trend analysis to guide strategy.
  • Advanced familiarity with AI tools and large language models such as Claude, Gemini, and ChatGPT.
  • Preferred: coding certifications such as CPC, CCS, COC, or CIC.
  • Preferred: experience operating in a Medicare-focused environment and with claim payment quality programs.

Benefits

  • Competitive base salary of $150,000 to $195,000 USD.
  • Equity opportunities, including an Employee Stock Purchase Plan with discounted shares.
  • Performance-based bonus program and 401(k) matching.
  • Comprehensive medical, dental, and vision coverage.
  • Remote-first work culture with collaboration and flexibility.
  • Generous flexible time-off policy, plus No-Meeting Fridays and monthly company holidays.
  • Mental health resources and work-life balance support.
  • Learning programs, mentorship, professional development funding, and regular performance feedback.
  • Paid parental leave for all new parents.
  • Office setup reimbursement and a monthly cell phone and internet stipend.

Interested in this position?

Apply directly on the company website

Apply Now

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