Clover Health - Director, Claim Payment Accuracy

• By the end of your initial 90-day period: You will have established a recurring monthly claims review framework designed for maximum enterprise impact. This process will utilize a hybrid approach: broad-spectrum random sampling to ensure baseline quality, alongside targeted, judgmental audits focused on high-impact enterprise risk across policies, pricing, and contract terms. • By the end of your initial 90-day period: • By 6 months: You will have ensured that all clinical and reimbursement policies are current and that benefit and pricing oversight is fully integrated into our adjudication monitoring. You will be actively leveraging AI tools like Claude, Gemini, and ChatGPT to build out ongoing monitoring and oversight trends that identify high-impact risks to support judgmental sampling and targeted audits. • Claude, Gemini, and ChatGPT • Continued success: You will lead Clover to market-leading "Clean Claim" and "Payment Accuracy" rates. By championing automated monitoring and data-driven research, you will evolve the team into a proactive strategic powerhouse, ensuring Clover's payment ecosystem achieves top-tier precision and technological sophistication. • Continued success: • You should get in touch if: • You have 8+ years of leadership experience in healthcare claims, payment accuracy, or policy oversight, with a heavy emphasis on Medicare Advantage. • You are an expert in HealthEdge HRP and Source, with a deep understanding of how these systems interact to drive adjudication accuracy. • You are extremely AI-forward—you are passionate about how emerging technologies and LLMs (Claude, Gemini, ChatGPT) can be applied to drive operational precision in monitoring and research. • You have a proven ability to lead through influence, navigating complex cross-functional relationships to drive systemic change. • You are a Medicare expert with a proven track record of interpreting and operationalizing complex clinical policies, pricing models, and reimbursement guidelines. • You have extensive experience providing oversight for vendor relationships at a strategic level, ensuring partners meet rigorous performance standards. • You are a data-focused leader who builds strategy based on sophisticated dashboards and trend analysis. • You are a master of cross-functional influence, able to align diverse teams around a unified vision of payment excellence. • Preferred qualifications include coding certifications such as CPC, CCS, COC, or CIC.