Jobs at Clever Care Health Plan Inc.

Manages quality and risk performance for provider organizations in a Medicare Advantage network. Educates providers on HEDIS, Stars, CAHPS, risk adjustment, coding, and regulatory requirements; analyzes and reconciles performance data; supports chart reviews, action plans, quality initiatives, medication adherence programs, and member outreach. Leads recurring provider meetings, presentations, workgroups, and follow-up on improvement actions while collaborating with internal teams, vendors, MSOs, IPAs, and community representatives.

Leads quality assurance for enterprise data integrations, data warehouses, ETL pipelines, APIs, reporting datasets, and analytics platforms. Designs test strategies, validates mappings and transformations, performs reconciliation and regression testing, investigates defects, and supports production releases. The role also develops testing standards, improves automation and data-quality monitoring, participates in Agile ceremonies, coordinates with vendors and technical teams, and mentors junior QA analysts.

Provide clinical pharmacy support for a Medicare Advantage plan: review Part D/B cases, support MTM and formulary/UM processes, oversee PBM interactions, ensure CMS compliance and audit readiness, coach technicians, drive medication adherence and quality initiatives, and improve workflows with data and culturally attuned member experience.

Perform independent audits of Medicare Part D clinical compliance including CDAG, MTM program elements, and delegated PBM controls. Validate timeliness, notice content, targeting and CMR/TMR completion, track corrective actions, coordinate benefit boundary issues with UM/Part C, and prepare dashboards and Board-level reports to ensure regulatory readiness and member impact remediation.

Conduct retrospective, prospective, and targeted coding audits and diagnosis validation reviews to ensure accurate ICD-10-CM/HCC coding and CMS Risk Adjustment compliance. Support RADV readiness, vendor oversight, provider education, root cause analysis, audit reporting, and continuous quality improvement to improve documentation integrity and risk score accuracy.