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Clover Health

Clover Health is a unique health insurance plan focused on driving down costs and producing improved health outcomes.

Operations Lead, Claims
United States of America
Job Description / Skills Required

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

The Claims team is a group of dedicated, hard-working, enthusiastic individuals working at the heart of service operations. This team maintains the business function of our claims and activities, including ensuring accuracy and timeliness of claims processing, maintaining CMS compliance, and resolving escalated issues. The team also works on projects to improve the efficiency and accuracy of cross-functional activities of Service Operations. The success of service operations relies on collaboration with our internal counterparts: Payment Integrity, Provider Data Management, Utilization Management, Appeals, Network, and Customer Experience.

We are looking to hire an Operations Lead of Claims to improve the productivity of Clover's claims function through strong organizational skills and operational oversight. In this role you will be responsible for overseeing and maximizing the relationship with our Business Process Outsourcing (BPO) vendor through driving day-to-day interactions, while also ensuring adherence to SLA's and compliance with Clover's internal policies and procedures.

As a Claims Lead you will:

  • Develop relationships, own communications, and drive day-to-day interactions with BPO.
  • Lead routine calls with BPO and maximize team efficiency by gathering all updates prior to calls and meetings.
  • Ensure BPO and plan are aligned in terms of expectations, performance and release/delivery timeframes.
  • Partner with leadership and team members to develop audit and oversight plans.
  • Hold BPO and/or internal resources accountable to deadlines, deliverables and remediation plans. Raise concerns or issues to leadership.
  • Research and address issues with BPO. Track and trend incidents, change requests and other tickets across multiple platforms.
  • Analyze processes and provide recommendations for improvement or remediation of issues.
  • Analyze vendor performance in comparison with SLAs and CMS requirements. Develop and maintain vendor performance scorecards.
  • Develop and track work plans and assist in establishing operational objectives. Identify appropriate resources to support specific tasks and ensure resources are engaged and performing.
  • Perform other duties as assigned.

You will love this job if:

  • You want to make an impact. You thrive off of helping others, and want your work to make a difference in our members' lives.
  • You are a team player. You enjoy partnering with others, and want to work collaboratively to find new solutions.
  • You are a strong communicator. You have strong verbal and written communication skills that foster trust, knowledge sharing, and progress.
  • You are detail-oriented. You pay attention to the small things, while understanding how they fit into the bigger picture.
  • You are motivated to learn. There is no shortage of technical, clinical, and operational skills to learn at Clover.
  • You are curious. You like to do research when you don't know an answer. You ask the hard questions and you don't sweep problems under the rug.

You should get in touch if:

  • You have 2-3 years of vendor/BPO management and oversight experience.
  • You have 3-5 years of Medicare Claims experience.
  • You have 1 to 3 years of experience working in the Facets or HealthRules Payor systems.
  • You're a strong communicator with proven experience developing and maintaining professional relationships.
  • You can effectively multitask and are able to decipher reports/dashboards and produce presentations and diagrams.

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.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences and backgrounds, who share 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. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

Clover Health welcomes qualified candidates with disabilities and will provide accommodations during the interview process as needed. If you require accommodations, please email with the details of your requested accommodation. Requests are reviewed by a member of the recruiting team. Requests will have no bearing on the candidate evaluation process or hiring decisions.