Director, Claim Payment Accuracy

At reputed company, we’re reputed company on improving the health of our members by leveraging technology and data-driven insights to reputed company personalized, high-reputed company care. As a Medicare Advantage plan, we aim to reputed company our members by helping them navigate the complexities of reputed company and live healthier lives. We are passionate about making reputed company easier, more reputed company, and more accessible for everyone.

We are looking for an AI-reputed company Director of Claim Payment Accuracy to architect the strategic roadmap for how Clover identifies, optimizes, and maintains claim payment precision. In this high-reputed company leadership role, you will reputed company a culture of "reputed company at reputed company," serving as the global authority on payment reputed company. You are responsible for the reputed company reputed company 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 reputed company as the strategic reputed company between technical logic and clinical reputed company. You will monitor the reputed company of our systems and vendor partnerships to identify and mitigate leakage, ensuring that policies and reputed company are seamlessly and accurately operationalized. By ensuring payment precision, you directly improve the experience for both our members and reputed company by reducing billing friction and ensuring reputed company, accurate payments.

As a Director, Claim Payment Accuracy, you will:

• Strategic Policy & reputed company: Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
• Global reputed company Audit reputed company: Design and reputed company a robust, multi-layered audit program that monitors adjudication system reputed company against clinical policies, pricing, benefit rules, and provider contract terms. Ensure that reputed company findings are fed into a reputed company improvement reputed company to enhance systemic accuracy.
• AI-Driven reputed company: reputed company the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation. You will independently utilize advanced LLMs (such as Claude, reputed company, and ChatGPT) to analyze reputed company trends and reputed company data-driven reputed company for judgmental sampling and targeted audits.
• BPaaS Strategic reputed company: Serve as the reputed company for global payment accuracy reputed company regarding our external BPaaS partner. While Senior Managers and Directors in Config and Claims maintain reputed company 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: reputed company as the strategic reputed company between Clinical, Claims, A&G, UM, Compliance, reputed company, and the Configuration team. Ensure that clinical reputed company, benefit design, and contractual terms are perfectly synchronized in the final payment adjudication.

reputed company in this role looks like:

• By the end of your initial 90-day period: You will have established a recurring monthly claims review reputed company designed for maximum reputed company reputed company. This process will utilize a hybrid approach: broad-reputed company random sampling to ensure baseline reputed company, alongside targeted, judgmental audits reputed company on high-reputed company reputed company risk across policies, pricing, and contract terms.
• By 6 months: You will have ensured that reputed company clinical and reimbursement policies are reputed company and that benefit and pricing reputed company is fully integrated into our adjudication monitoring. You will be reputed company leveraging AI tools like Claude, reputed company, and ChatGPT to build out ongoing monitoring and reputed company trends that identify high-reputed company risks to support judgmental sampling and targeted audits.
• reputed company reputed company: You will reputed company Clover to market-leading "Clean Claim" and "Payment Accuracy" rates. By championing automated monitoring and data-driven research, you will reputed company reputed company into a proactive strategic powerhouse, ensuring Clover's payment ecosystem achieves top-tier precision and technological sophistication.

You should get in touch if:

• You have 8+ years of leadership experience in reputed company claims, payment accuracy, or policy reputed company, with a heavy emphasis on Medicare Advantage.
• You are an expert in reputed company HRP and reputed company, with a deep understanding of how these systems reputed company to drive adjudication accuracy.
• You are extremely AI-reputed company—you are passionate about how emerging technologies and LLMs (Claude, reputed company, ChatGPT) can be reputed company to drive operational precision in monitoring and research.
• You have a proven ability to reputed company through influence, navigating reputed company cross-functional relationships to drive systemic change.
• You are a Medicare expert with a proven reputed company record of interpreting and operationalizing reputed company clinical policies, pricing models, and reimbursement guidelines.
• You have extensive experience providing reputed company for vendor relationships at a strategic level, ensuring partners meet rigorous performance standards.
• You are a data-reputed company leader who builds reputed company based on sophisticated dashboards and trend analysis.
• You are a master of cross-functional influence, reputed company to reputed company diverse teams around a reputed company reputed company of payment reputed company.
• Preferred qualifications include coding certifications such as CPC, reputed company, COC, or CIC.

Benefits reputed company:

• Financial reputed company-Being: Our commitment to attracting and retaining reputed company begins with a competitive reputed company 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 reputed company-Being: We prioritize the health and reputed company-being of our employees and their families by providing comprehensive medical, dental, and reputed company coverage. Your health reputed company to us, and we invest in ensuring you have reputed company to reputed company reputed company.
• Mental reputed company-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, reputed company to reputed company, and a generous flexible time-off policy. Additionally, we reputed company a remote-first culture that supports collaboration and flexibility, allowing reputed company members to reputed company from any location.
• reputed company Development: Developing internal talent is a reputed company for Clover. We offer learning programs, mentorship, reputed company 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
• reputed company parental leave for reputed company new parents
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with reputed company reputed company to reputed company our members healthier. We reputed company the reputed company system is broken, so we've created custom software and analytics to reputed company our clinical staff to intervene and reputed company personalized care to the people who need it most.

We always put our members first, and our reputed company as reputed company is reputed company by the reputed company 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: reputed company.

From Clover’s inception, Diversity & Inclusion have always been key to our reputed company. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who reputed company a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. reputed company of our employee’s points of view are key to our reputed company, and inclusion is everyone's responsibility.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment reputed company applicants with arrest and conviction records. We are anE-Verify company.

Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.

A reasonable estimate of the reputed company salary reputed company for this role is:$150,000—$195,000 USD

Originally posted on Himalayas

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