Operations Associate Payment Integrity

About the Role

The Payment Integrity team operates at the core of Clover Health's mission to provide high-quality, affordable healthcare plans. By leveraging advanced data management and spreadsheeting techniques, you will be responsible for facilitating the aggregation of high-volume claim batches for reprocessing and ensuring the precision of these batches prior to final submission. Your contributions will be crucial in driving value for every member by ensuring that medical claims are paid accurately and that recoveries are facilitated efficiently.

What You Will Do

• Execute Claim Reprocessing Cycles: Facilitate the aggregation of high-volume claim batches for reprocessing, utilizing advanced data management and spreadsheeting techniques to merge, review, and validate cycles of claim adjustments.
• Perform Reprocessing Reconciliations: Facilitate backend controls to audit the accuracy of batch-reprocessed claims and conduct comprehensive reconciliations to ensure that all expected adjustments are accurately reflected.
• Collaborate with Internal and External Stakeholders: Work closely with various teams, including provider relations, data infrastructure, and software development, to ensure seamless coordination and communication.
• Analyze Data Trends: Identify trends and anomalies in claim data to inform process improvements and optimize payment integrity operations.
• Develop and Maintain Documentation: Ensure that all processes and procedures related to payment integrity are well-documented and kept up-to-date.
• Participate in Quality Assurance: Contribute to quality assurance efforts to ensure that payment integrity operations are meeting high standards of accuracy and compliance.
• Stay Updated on Regulatory Changes: Stay informed about changes in healthcare regulations and ensure that payment integrity operations are compliant with these changes.
• Identify Opportunities for Process Improvement: Continuously look for opportunities to improve the efficiency and effectiveness of payment integrity processes.
• Coordinate Training and Support: Assist in the coordination of training and support for internal stakeholders on payment integrity processes and procedures.
• Participate in Project Initiatives: Contribute to project initiatives aimed at improving payment integrity operations and the overall quality of care provided by Clover Health.

What We Are Looking For

• 2+ years of experience in a related field, such as healthcare operations, data analysis, or a similar role.
• Strong data management and spreadsheeting skills, with the ability to work with large datasets.
• Excellent analytical and problem-solving skills, with the ability to identify and resolve issues efficiently.
• Strong communication and collaboration skills, with the ability to work effectively with diverse stakeholders.
• Knowledge of healthcare regulations and compliance standards.
• Experience with claim processing systems and software.
• Bachelor's degree in a related field, such as healthcare administration, business, or a similar field.
• Certification in a related field, such as healthcare compliance or data analysis, is a plus.
• Experience working in a fast-paced, dynamic environment, with the ability to adapt to changing priorities.

Nice to Have

• Experience with data visualization tools and techniques.
• Knowledge of programming languages, such as Python or R.
• Experience with project management methodologies and tools.
• Certification in project management or a related field.
• Experience working in a remote or distributed team environment.

Benefits and Perks

• Competitive salary and benefits package.
• Opportunity to work with a pioneering healthcare technology company.
• Collaborative and dynamic work environment.
• Professional development opportunities, including training and education support.
• Flexible work arrangements, including remote work options.
• Comprehensive health insurance package.
• Access to the latest technology and tools.
• Recognition and reward for outstanding performance.

• To stand out, highlight your experience with data management and spreadsheeting techniques, and be prepared to provide examples of how you have used these skills in previous roles.
• Ensure your portfolio includes any relevant projects or certifications that demonstrate your ability to work with complex data systems and healthcare regulations.
• Practice answering behavioral questions that assess your problem-solving skills, such as how you would handle a discrepancy in claim data.
• Research Clover Health's mission and values to understand the company culture and be prepared to discuss how your skills and experience align with these.
• Be prepared to discuss your experience working in a fast-paced environment and how you adapt to changing priorities.
• When negotiating salary, consider the overall benefits package and the opportunity for professional growth within the company.
• Be cautious of roles that do not offer clear paths for professional development or that have unclear expectations regarding work responsibilities and boundaries.