Senior Operations Associate, Claims

Clover Health, San Francisco, CA

Clover is a Medicare Plan done differently.

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

As an Operations Associate at Clover, you will play an active role in developing, managing, and scaling our Claims adjudication and monitoring function. We are looking for a candidate with strong experience in Medicare claims adjudication who has a strong conviction that health insurance can and should be better.

The Claims team is a group of dedicated, hard-working, enthusiastic individuals working at the heart of insurance operations. This team maintains the business function of any claims related activities, including claims monitoring, payment disputes, escalated provider inquiries, and system claims system configuration. The team also works on projects to improve the efficiency and accuracy of its own operations. The success of insurance operations relies on collaboration with our internal counterparts: Membership, Utilization Management, Claims, Appeals, Grievances, Customer Service, and Provider Data.

We're looking for someone who can learn, adapt, and grow with Clover's mission to change the payer landscape for the better. The Manager will conceptualize and drive execution of experiments across service design, operational workflows, and logistics in a way that is iterative, data-driven, and with an eye towards technology-enabled scalability.

As an Operations Associate, you will:

  • Manage a team of 20 employees total with 5 leads reporting directly to you; teams include claims monitoring, payment disputes, provider escalations, and benefit and contract configuration.
  • Provide strategies and development that contribute to the growth of the claims and payment disputes teams and drive process improvements.
  • Partner with Product Managers and Data Engineers to develop tools and automation to improve team efficiency, auto-adjudication rate, and innovate on how claims processing is executed.
  • Design and drive process and workflow implementation both internally and with vendors - and act as critical escalation point.
  • Incorporate cross-functional perspectives and business needs in solving complex problems.
  • Create and report on key business metrics related to claims including overall quality, timeliness, medical expense and individual productivity metrics.
  • Ensure Clover is in compliance with all CMS claims regulations.
  • Forecast claims volume and required staffing levels to meet quality and timeliness metrics.
  • Support the entire Clover organization with escalation support for claims-related inquiries, both internal and external.

You will love this job if:

  • You are a people-oriented leader with a track record of mentoring, developing, and motivating peers and direct reports.
  • You enjoy empowering others and democratizing data and understandings. You're metrics driven and know how to use data to make better decisions.
  • You're a true collaborator and believe in working cohesively with other departments to move things forward.
  • You feel a deep sense of ownership and accountability for maintaining the health of your team and business impact and you drive responses and change toward a meaningful team direction.
  • You're excited to innovate and improve core processes of health insurance - many of which haven't changed in decades.
  • You thrive in fast-paced, ambiguous environments and execute with speed and a bias towards action.

You should get in touch if:

  • You have 2+ years prior experience working in an environment that blends technology and operations.
  • You have 3+ years of experience in Medicare or Medicare Advantage claims operations/management.
  • You have experience managing large complex teams.
  • You understand how claims operations touches different areas within insurance operations.

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

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.

We always put our members first, and our success as a team is measured by the quality 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: healthcare.

About Clover Health

Clover Health is a data driven health insurance startup driving to improve the overall state of healthcare in America. We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road. Unlike other health insurance companies also embracing preventive health, Clover’s Medicare is built on technology from the ground-up. Integrating our systems with doctors, clinicians, and nurse practitioners, Clover’s data team helps healthcare professionals in the field intervene directly into patients’ wellness to help them avoid acute health episodes. If you’re a passionate person and interested in changing healthcare for the better, then Clover may just be the place for you.

Clover Health

Want to learn more about Clover Health? Visit Clover Health's website.