Senior Manager, Strategic Configuration

About Clover Health

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.

Role Overview

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.

Key Responsibilities

• 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.
• 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.
• 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 Metrics

• 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 configuration logic remains at the forefront of the industry.