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 a strategist and technical Senior Manager of Strategic Configuration to lead the evolution of our first-pass claim payment accuracy. While our core configuration team handles daily "business as usual" workflows, this role is a highly specialized, strategic position focused on ensuring claims are paid correctly and precisely the first time.
In this role, you will lead a lean, agile team, acting as the strategic lead for enhancing the accuracy of the initial adjudication cycle. This requires a "player-coach" who can "get in the weeds" of technical configuration—specifically regarding contract logic, clinical edits, and reimbursement rules—while maintaining the strategic mindset needed to drive industry-leading precision. Your mission is to identify and address configuration gaps, refine edit logic, and implement advanced process flows that maximize first-pass accuracy, effectively reducing administrative friction and retrospective adjustments for both members and provider partners.
As a Senior Manager, Strategic Configuration, you will:
- First-Pass Accuracy Architecture: Lead the technical design and implementation of strategic configuration logic to ensure flawless first-pass adjudication. Ensure that complex member benefits and provider contract terms are perfectly synchronized with our accuracy goals.
- Strategic Process Optimization: Identify and address configuration gaps by optimizing edit logic and implementing enhanced precision-based review triggers to ensure payment precision at the point of initial intake.
- Evolution of Automated Solutions: Lead the integration of automated solutions to improve efficiency and accuracy in plan configuration. Utilize data-forward strategies to analyze configuration data, identify trends, and proactively mitigate payment inaccuracies.
+1 - Cross-Functional Synergy: Act as the primary strategic bridge between Configuration, Payment Integrity, Clinical Review, and Compliance. Ensure that plan designs and regulatory requirements are translated into actionable, high-precision configuration logic.
+1 - Lean Team Leadership: Provide hands-on, "player-coach" leadership for a small, high-impact team of specialists, fostering a culture of excellence, accountability, and continuous technical learning.
- Technical Documentation: Develop best practices and documentation for advanced configuration procedures.
Success in this role looks like:
- By the end of your initial 90-day period: You will have conducted a deep-dive assessment of our first-pass accuracy landscape, identifying key configuration gaps in current process flows and specifically targeting opportunities for edit optimization to reduce payment variances.
- By 6 months: You will have implemented strategic process flows and enhanced precision-based review triggers that align configuration with payment integrity and clinical review requirements. During this time, you will have established a refined "accuracy-by-design" workflow that ensures claims are adjudicated correctly during the initial pass.
- Continued success: You will lead Clover toward a market-leading first-pass payment accuracy rate. By championing automated solutions and predictive modeling, you will ensure our payment ecosystem is one of the most accurate and technologically advanced in the Medicare Advantage space.
You should get in touch if:
- You have 7+ years of experience in Medicare Advantage or healthcare plan configuration, with at least 3 years in a leadership or managerial role.
- You possess "in the weeds" expertise in technical configuration, specifically regarding complex provider contracts, clinical edits, and general reimbursement logic.
- You are highly proficient in health plan systems such as HealthEdge HRP and Source.
- You demonstrate strong project management and problem-solving abilities with a proven track record of driving systemic process improvements.
- You are passionate about leveraging technology and data-driven insights to drive operational precision.
- You have excellent verbal and written communication skills with the ability to translate complex technical concepts for diverse stakeholders.
Benefits Overview:
- Financial Well-Being: 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.
- Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
- Mental Well-Being: 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.
- Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
Additional Perks:
- 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
- And much more!
About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.
We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.
From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.
#LI-REMOTE
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.
