Jobs at Clever Care Health Plan Inc.

Coordinates risk adjustment operations between coders, providers, and internal teams. Provides compliant HCC documentation and coding education, analyzes risk adjustment trends, supports provider workflow improvements, tracks corrective actions, and maintains audit readiness. The role promotes accurate documentation, HCC recapture, coding quality, CMS compliance, and measurable provider performance improvements across Medicare Advantage practices.

Leads Medicare Advantage Risk Adjustment, Stars, HEDIS, and CAHPS operations; manages provider performance, analytics, dashboards, vendors, compliance, audits, and continuous improvement. Coordinates cross-functional initiatives, translates data into action plans, oversees operational KPIs, and develops a quality and risk adjustment team. The role supports CMS and NCQA readiness, provider engagement, incentive programs, reporting automation, and performance improvement across health plan operations.

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.

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.