Operations Associate, Payment Integrity

Clover is reinventing health insurance by working to keep people healthier. At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most. The Payment Integrity team is a motivated, collaborative team sitting at the intersection of Clover's provider relationship operations, data infrastructure, and software. The Payment Integrity team ensures that Clover pays claims in a fair, transparent, compliant, and medically justified manner. Come join us as we discover new opportunities to improve the financial health of Clover while strengthening provider relationships and building a better healthcare system. As an Operations Associate for Payment Integrity at Clover Health, you will play a key role in facilitating the underlying processes that support various cost containment work streams. You will help drive value for every member by ensuring that Clover’s medical claims are paid accurately and be responsible for facilitating recoveries on a growing membership base while supporting coordination between internal and external stakeholders. As an Operations Associate, Payment Integrity, you will: Execute Claim Reprocessing Cycles: Facilitate the aggregation of high-volume claim batches for reprocessing. Utilize advanced data management and spreadsheeting techniques to merge, review, and validate cycles of claim adjustments, ensuring precision prior to final submission. Perform Reprocessing Reconciliations: Facilitate backend controls to audit the accuracy of batch-reprocessed claims. Conduct comprehensive reconciliations to ensure that all expected adjustments are captured and processed without discrepancy. Manage Recovery Posting Resolution: Reconcile claims data to determine the accuracy and completeness of reprocessed claims. Oversee the audit software environment to control resolution tracking and ensure official recovery recognition aligns with Payment Integrity standards. Optimize Audit Letter Workflows: Manage the end-to-end administration of audit communications, including the extraction of data, secure SFTP transfers, rigorous proofing of member/provider letters, and the successful upload of files to external systems and vendors. Maintain Status Reconciliation: Perform ongoing monitoring and maintenance of audit software to validate the integrity of the audit population. Proactively research and resolve aging audits to minimize inventory lag and ensure timely recovery. Collaborate Across Functions: Partner with the Claims Adjustment Team, Provider Services, and key internal stakeholders to resolve escalated payment issues and optimize recovery outcomes while preserving strong provider partnerships. Drive Process Excellence: Develop and refine process documentation, workflows, and standard operating procedures (SOPs) to strengthen team capabilities and maximize operational efficiency. Success in this role looks like: By the end of your initial 90-day period, you have seamlessly integrated into the Payment Integrity Team and established strong relationships with key internal partners. You have developed a foundational knowledge of the audit software and the end-to-end recovery workflows, successfully executing your first cycles of claim batch aggregation and audit letter distributions. By 6 months, you will be independently managing the recovery posting process and performing complex reprocessing reconciliations. You will be recognized as a subject matter expert in status reconciliation, effectively reducing the volume of aging audits and ensuring the accuracy of all recovery data reported by the department ... (truncated, view full listing at source)