Director, Claim Payment Accuracy

Clover Health

1d•$150,000 - $195,000•Remote

About The Position

At Clover Health, we’re focused on improving the health of our members by leveraging technology and data-driven insights to provide personalized, high-quality care. As a Medicare Advantage plan, we aim to empower our members by helping them navigate the complexities of healthcare and live healthier lives. We are passionate about making healthcare easier, more affordable, and more accessible for everyone. We are looking for an AI-forward Director of Claim Payment Accuracy to architect the strategic roadmap for how Clover identifies, optimizes, and maintains claim payment precision. In this high-impact leadership role, you will lead a culture of "Quality at Scale," serving as the global authority on payment outcomes. You are responsible for the quality oversight of claim payments and the ongoing maintenance of our clinical and reimbursement policies, ensuring that pricing, benefit rules, and contract terms result in flawless adjudication. While you will not manage the configuration team directly, you will act as the strategic bridge between technical logic and clinical intent. You will monitor the output of our systems and vendor partnerships to identify and mitigate leakage, ensuring that policies and contracts are seamlessly and accurately operationalized. By ensuring payment precision, you directly improve the experience for both our members and provider partners by reducing billing friction and ensuring timely, accurate payments.

Requirements

8+ years of leadership experience in healthcare claims, payment accuracy, or policy oversight, with a heavy emphasis on Medicare Advantage.
Expert in HealthEdge HRP and Source, with a deep understanding of how these systems interact to drive adjudication accuracy.
Extremely AI-forward—passionate about how emerging technologies and LLMs (Claude, Gemini, ChatGPT) can be applied to drive operational precision in monitoring and research.
Proven ability to lead through influence, navigating complex cross-functional relationships to drive systemic change.
Medicare expert with a proven track record of interpreting and operationalizing complex clinical policies, pricing models, and reimbursement guidelines.
Extensive experience providing oversight for vendor relationships at a strategic level, ensuring partners meet rigorous performance standards.
Data-focused leader who builds strategy based on sophisticated dashboards and trend analysis.
Master of cross-functional influence, able to align diverse teams around a unified vision of payment excellence.

Nice To Haves

Coding certifications such as CPC, CCS, COC, or CIC.

Responsibilities

Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
Design and oversee a robust, multi-layered audit program that monitors adjudication system output against clinical policies, pricing, benefit rules, and provider contract terms. Ensure that all findings are fed into a continuous improvement loop to enhance systemic accuracy.
Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies and contract validation. You will independently utilize advanced LLMs (such as Claude, Gemini, and ChatGPT) to analyze oversight trends and develop data-driven criteria for judgmental sampling and targeted audits.
Serve as the lead for global payment accuracy oversight regarding our external BPaaS partner. While Senior Managers and Directors in Config and Claims maintain direct operational relationships for their respective areas, you will hold the vendor to world-class standards through global accuracy reviews and data-driven performance monitoring.
Act as the strategic bridge between Clinical, Claims, A&G, UM, Compliance, Quality, and the Configuration team. Ensure that clinical intent, benefit design, and contractual terms are perfectly synchronized in the final payment adjudication.