Jobs at Clever Care Health Plan Inc.

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.

Serve as the front‑desk point of contact for visitors, members, and staff. Manage phone lines, schedule appointments and conference rooms, handle mail and deliveries, perform clerical tasks (filing, scanning, data entry), maintain supplies, support events, and protect sensitive HIPAA information while maintaining a professional reception area.

Manage intake, investigation, documentation, and resolution of Medicare Advantage member grievances, appeals, and provider disputes per CMS, NCQA, state, and contractual requirements. Track cases to meet turnaround times, prepare determination letters and supporting documentation, support CTM and audit/universe submissions, coordinate with clinical and operational teams, identify trends for quality improvement, and maintain audit-ready case files. Assist Member Services during high-volume periods.

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.