Director, Claim Payment Accuracy

2 months, 2 weeks ago
Full-time
Executive
Data Science and Analytics
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

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

Similar Roles

Production Primary Scheduler

Green Thumb Industries 1K-5K Pharmaceuticals

Green Thumb is hiring a Primary Production Scheduler to own network-wide production planning for pre-roll manufacturing and flower packaging while leading and standardizing the scheduling function across multiple sites.

ERP
13 hours, 19 minutes ago

Electrical Manager - FieldWorks

The Nuclear Company is hiring a Manager, Electrical FieldWorks to build and lead union electrical field capabilities supporting maintenance, testing, commissioning, outage, and project work across nuclear and energy sites.

Transformers
13 hours, 19 minutes ago

Virtual Supervising Physician (Telehealth) - Remote

Ennoble Care 51-250 Health Care Providers & Services

Ennoble Care is seeking a Virtual Supervising Physician to provide annual oversight, telehealth care, and supervision for a panel of homebound Medicare patients across its multi-state home-based care program.

1 day, 12 hours ago

Supervisor, Clinical Services

Amwell 1K-5K Diversified Telecommunication Services

Amwell is hiring a Clinical Supervisor for SilverCloud Health to oversee clinical governance and day-to-day support for digital mental health services on a 6-month, part-time contract.

1 day, 12 hours ago

You're on a roll! Sign up now to keep applying.

Sign Up

Already have an account? Log in

Used by 14,729+ remote workers