Operations Associate, Payment Integrity

Summary

Join Clover Health's Payment Integrity team as an Operations Associate and play a key role in facilitating processes supporting cost containment. You will ensure accurate medical claim payments, facilitate recoveries, and coordinate with internal and external stakeholders. Responsibilities include managing vendor solutions for accurate billing, monitoring claims inventory, communicating with vendors, supporting the recovery process, validating claim adjustments, resolving payment issues, collaborating with team members, and developing process documentation. The ideal candidate possesses a Bachelor's degree or equivalent experience, 2+ years in healthcare with payment integrity exposure, proficiency in Excel/Google Sheets, knowledge of CMS rules and regulations, and claims processing/project management/auditing experience. Success involves seamless team integration, strong partner relationships, and foundational workflow knowledge within 90 days, progressing to supporting end-to-end operations and managing the recoupment process within 6 months. Future success requires strong data management, innovative thinking, and a results-centric approach.

Requirements

• You have a Bachelor's degree or equivalent professional experience with 2+ years in healthcare, including exposure to health plan payment integrity practices
• You have experience in healthcare and can easily demonstrate proficiency with Excel or Google Sheets
• You have knowledge of CMS rules and regulations combined with hands-on claims processing, project management, or auditing experience

Responsibilities

• Facilitate the end-to-end processes of time sensitive vendor solutions deployed to ensure accurate billing and appropriate provider reimbursement
• Monitor, analyze, and report on claims inventory to ensure adherence to CMS timelines and Clover’s policies
• Effectively communicate with vendor liaisons to maintain all operational aspects programs in scope
• Support the broader Payment Integrity recovery process by preparing and managing high volumes of claims data
• Validate the accuracy of claim adjustment requests through comprehensive reconciliations and continuous monitoring
• Research and resolve escalated payment issues identified as the result of Payment Integrity initiatives
• Collaborate with Payment Integrity Team Members, Claims Adjustment Team, Provider Services, and key stakeholders to optimize outcomes while preserving strong provider partnerships
• Develop and refine process documentation, workflows, and standard operating procedures to strengthen team capabilities
• Support subject matter experts in improving team efficiency and maximizing return on investment through process optimization

Preferred Qualifications

You have SQL and statistical analysis capabilities, medical coding certifications (AAPC/AHIMA), healthcare analytics platform experience, and knowledge of value-based care models

Benefits

• Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities
• Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions
• We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage
• We understand the importance of mental health in fostering productivity and maintaining work-life balance
• To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy
• Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location
• Developing internal talent is a priority for Clover
• We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for all new parents