Sorry. This page is not yet translated.
Clover Health

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

Claims Operations Specialist
San Francisco, CA, US
Job Description / Skills Required

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

Our Claims Team is a group of dedicated, hard-working, enthusiastic individuals working at the heart of insurance operations. We strive to uphold compliance timeliness and accurate resolution of payment disputes and appeals. We have adopted a collaborative approach with various counterparts to drive processes that will be sustainable and effective. We thrive on each other's success and are thoughtful in refining skills that will elevate capabilities across the team.

As a specialist within the Claims team, you will be a vital contributor to ensuring that Clover researches and responds to claims payment disputes accurately and within defined timeframes. You will work with various teams across Clover, contributing expert input to improve processes and address operational issues. You will be joining a fast-growing and fast-moving startup at the intersection of healthcare and technology where you will have the chance to develop both your analytical and operational skills.

As a Claims Operations Specialist, you will:

Appropriately monitor all payment disputes using various dashboards, databases, and ticketing systems to ensure compliance standards are met.
Research issues raised by members and/or providers to resolve payment disputes accurately.
Act as a liaison for our internal departments to communicate effectively to our Members and Providers.
Prepare response letters to deliver our decisions to member and/or provider within the regulatory timeframes set forth by the Centers for Medicare & Medicaid Services (CMS).
Escalate complex claim issues to the Payment Disputes Lead when necessary.
Collaborate closely with the Claims and Payment Integrity teams to identify higher-level patterns in payment disputes to address root causes.

You will love this job if:

You are extremely thorough, organized, and process-oriented. You have great follow-up skills and can prioritize your work.
You enjoy provider interactions. You value a high level of service and are eager to ensure all our providers are well represented.
You are excited to dive into autonomous work. Managing tasks/projects and driving them to completion motivates you to come into work.
You understand that compliance is not just a set of rules you follow—it's the way you work. Be able to engrain the importance of being compliant with the work you produce.
You are responsive to changes in policies and team direction. Be receptive to an ever-changing environment and iron out what can or cannot work.
You like to learn. Healthcare and technology are complicated. You are passionate about understanding how these two things come together.
You thrive in a collaborative environment, working with teammates to progress through challenges and ambiguities.
You are interested in continuing a career in healthcare and want to contribute to tackling one of society's greatest challenges.

You should get in touch if:

You have had success working in team settings and working cross-functionally with various groups.
You demonstrate strong verbal, writing, and problem-solving skills.
You are comfortable with technology. Preferable if you have experience working with Google applications (i.e., Google Docs, Google Sheets).
Bonus if you have worked at a startup, in a healthcare setting and/or have experience with medical claims.

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.