Teams at Clever Care Health Plan Inc.

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.

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.