Jobs at Clever Care Health Plan Inc.

Leads Medicare Advantage sales strategy, enrollment growth, retention, broker distribution, and market development across Southern California counties. Manages and coaches sales staff, develops broker and agency relationships, establishes production goals, forecasts performance, analyzes market KPIs, and ensures compliance with CMS and applicable regulations. Requires extensive travel within the assigned market, hybrid office work, and collaboration with brokers, providers, community partners, and internal teams.

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.

Process non-complex paper and electronic Medicare Advantage claims from initiation to final adjudication, manage a caseload of 50–150 claims daily, investigate and determine compensability, authorize payments per CMS and plan guidelines, communicate with providers and clients, maintain documentation, participate in audits, and assist with related office tasks.

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.

Support member onboarding and enrollment by entering and verifying application data, resolving system rejections, responding to inquiries, maintaining eligibility records, reconciling files, and coordinating with internal teams to ensure accurate enrollments.

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.