At Clover Health, we’re focused on improving the health of our members by leveraging technology and data-driven insights to provide personalized, high-quality care. As a Medicare Advantage plan, we aim to empower our members by helping them navigate the complexities of healthcare and live healthier lives. We are passionate about making healthcare easier, more affordable, and more accessible for everyone.
We are looking for an AI-forward Director of Claim Payment Accuracy to architect the strategic roadmap for how Clover identifies, optimizes, and maintains claim payment precision. In this high-impact leadership role, you will lead a culture of "Quality at Scale," serving as the global authority on payment outcomes. You are responsible for the quality oversight of claim payments and the ongoing maintenance of our clinical and reimbursement policies, ensuring that pricing, benefit rules, and contract terms result in flawless adjudication.
While you will not manage the configuration team directly, you will act as the strategic bridge between technical logic and clinical intent. You will monitor the output of our systems and vendor partnerships to identify and mitigate leakage, ensuring that policies and contracts are seamlessly and accurately operationalized.
By ensuring payment precision, you directly improve the experience for both our members and provider partners by reducing billing friction and ensuring timely, accurate payments.
- Strategic Policy & Oversight: Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
- Global Quality Audit Framework: 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.
- AI-Driven Evolution: 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.
- BPaaS Strategic Synergy: Serve as the lead for global payment accuracy oversight regarding our external BPaaS partner. While Senior Managers and Directors in Config and Claims maintain direct operational relationships for their respective areas, you will hold the vendor to world-class standards through global accuracy reviews and data-driven performance monitoring.
- Cross-Functional Influence: Act as the strategic bridge between Clinical, Claims, A&G, UM, Compliance, Quality, and the Configuration team. Ensure that clinical intent, benefit design, and contractual terms are perfectly synchronized in the final payment adjudication.
- By the end of your initial 90-day period: You will have established a recurring monthly claims review framework designed for maximum enterprise impact. This process will utilize a hybrid approach: broad-spectrum random sampling to ensure baseline quality, alongside targeted, judgmental audits focused on high-impact enterprise risk across policies, pricing, and contract terms.
- By 6 months: You will have ensured that all clinical and reimbursement policies are current and that benefit and pricing oversight is fully integrated into our adjudication monitoring. You will be actively leveraging AI tools like Claude, Gemini, and ChatGPT to build out ongoing monitoring and oversight trends that identify high-impact risks to support judgmental sampling and targeted audits.
- Continued success: You will lead Clover to market-leading "Clean Claim" and "Payment Accuracy" rates. By championing automated monitoring and data-driven research, you will evolve the team into a proactive strategic powerhouse, ensuring Clover's payment ecosystem achieves top-tier precision and technological sophistication.
- 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.
- 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.
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 we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.