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Clover Health

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

Senior Manager, Risk Adjustment
United States of America
Job Description / Skills Required

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

Clover's Operations teams are responsible for building, designing, and implementing the systems, processes, and capabilities that help Clover succeed in our mission of improving health outcomes for our members and effecting change in the healthcare system. We collaborate with teams across the entire organization to ensure our members have access to the right care, at the right time, in the right setting.

In this role, you will be responsible for overseeing Clover's Risk Adjustment operations including day to day oversight for chart chase, coding, and submissions, the development & implementation of strategy to improve the department, and working with leadership to report out on progress/blockers. You will work closely with finance, data science, network management, clinical operations, product management, and vendor partners to meet Clover's business objectives and deadlines set forth by CMS.

As Sr. Manager, Risk Adjustment, you will:

  • Lead, monitor and identify opportunities to improve the efficiency, accuracy, and timeliness of chart chase, coding, and submission operations.
  • Partner with finance to ensure appropriate allocation of the risk adjustment program budget.
  • Manage risk adjustment vendor operations and agreements. This includes, reviewing and reporting out on ongoing performance metrics, comparing vendor fees, financial and quality performance against competitors.
  • Develop and track accurate diagnosis capture improvement initiatives including but not limited to clinical documentation improvement.
  • Drive reporting and analytics team in building operational dashboards that can be used to monitor progress.
  • Partner with leadership to set annual/quarterly goals and present monthly executive progress reports.
  • Partner with the Compliance department to ensure readiness in the case of a Risk Assessment Data Validation (RADV) audit.
  • Manage documentation process and oversight of vendor agreements. 
  • Create tools and training materials to stand up a successful risk adjustment program.
  • Support all Risk Adjustment Data Validation (RADV) related programs and conduct analytical studies that ensure accuracy and completeness of data submitted to CMS.
  • Work collaboratively with internal and external partners to achieve the goals and objectives of all data validation activities.

You will love this job if:

  • You are analytical, enjoy problem solving and have a high level of attention to detail.
  • You are great at prioritizing and executing multiple tasks that adhere to strict deadlines in a fast-paced, changing environment.
  • You are a team player, resourceful and can cultivate relationships with diverse groups of people to work efficiently.
  • You are nimble, and comfortable working in a constantly evolving environment. You embrace ambiguity and speed while maintaining a bias towards action.

You should get in touch if:

  • You have at least 5 years experience managing risk adjustment operations in a blended tech healthcare or Medicare environment.
  • You have direct experience with the technicalities of risk adjustment operations, including but not limited to, enhancement of RAPs and EDS submissions, industry standard outcome measures as well as, CMS response file reconciliation processes.
  • You have an understanding of chart chase, coding and submissions and experience working on related operations.
  • You have expert fluency and proficiency with CMS Risk Adjustment Methodology and HCC terminology.
  • You have excellent critical thinking skills, decision making capabilities and ability to communicate effectively.
  • Prior experience with RA team leadership 
  • Experience at managing significant projects to tight deadlines 
  • Experience with managing vendor relationships 
  • Experience with SQL and building and modifying queries.
  • You have start-up experience in an entrepreneurial setting, preferred but not required.

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.