Operations Coordinator, Utilization Management - Clover Health

Clover is reinventing health insurance by working to keep people healthier.

Utilization Management is responsible for ensuring Clover members have access to the right care at the right time in the right setting. Our clinical and operational staff work together to ensure timely and clinically appropriate decisions are made for all prior authorizations for Clover members in accordance with CMS compliance.

As the Utilization Management Operations Coordinator, you will be responsible for partnering with and monitoring Clover's vendors and in-house processes.

As an Operations Coordinator, you will:

• Assist with managing vendor relationships for non-clinical Utilization Management (UM), workflows.
• Monitor priority cases and report on key performance indicators.
• Maintain and organize internal UM policies and procedures.
• Support UM projects and process improvement initiatives.
• Perform quality assurance (QA) reviews of non-clinical UM processes to ensure accuracy, efficiency, and compliance with regulations.
• Assist with data entry and analysis to support UM reporting and decision-making.
• Identify and escalate procedural gaps and compliance concerns.
• Develop and implement operational SOPs, including training and QA.
• Resolve issues escalated by providers and vendors.
• Investigate complaints to Medicare (CTM).

Success in this role looks like:

• How is success measured in the first 90 days?
• Mastery of core tasks: Accurate and timely execution of case monitoring, data entry, and QA reviews. 
• Understanding of UM processes: Solid grasp of internal policies, procedures, and systems.
• Effective collaboration: Positive working relationships and clear communication with the team.
• How is success measured in the first 6 months?
• Increased efficiency: Streamlined workflows and improved task completion times.
• Proactive problem-solving: Identifies and resolves routine UM process issues.
• Contribution to improvements: Active participation in process enhancements.
• Consistent accuracy: High level of accuracy in all work.
• How will success be measured in the future?
• Process ownership: Takes ownership of key UM processes and demonstrates expertise.
• Leadership in improvements: Leads and implements impactful process enhancements.
• Contribution to goals: Supports departmental and organizational UM objectives.

You should get in touch if:

• You have knowledge and understanding of Medicare Advantage plans and CMS regulations.
• You have experience with Medicare insurance regulations (required).
• You have at least 1 - 2 years experience in healthcare and customer service.
• You have experience with Microsoft Suite and/or Google Docs.
• You have experience working remotely and have an appropriate office space.
• You have experience in completing quality assurance reviews.
• You enjoy managing large projects that require strong organizational skills and collaborating with a broad array of teams within an organization.
• You have acute attention to detail and always strive for perfection when writing formal documents.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive hourly rate. 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, company holidays, access to mental health resources, and a generous time-off policy.
• Full-time hourly employees accrue up to 18 days of vacation per year
• Clover recognizes 10 federal holidays including New Year's Day, Juneteenth, and Christmas. There are also 4 additional paid holidays, 1 floating holiday, and a Week of Rest (the last week of December)
• 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:

• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for all new parents

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 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.

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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.

Last updated: 23 hours ago