Lead RN, Utilization Management

2 hours, 4 minutes ago
Full-time
Lead
Operations
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised

Description

  • Lead, coach, and onboard UM nurses and clinical reviewers through audits and feedback.
  • Manage workloads, staffing coverage, and escalations across prospective, concurrent, and retrospective reviews.
  • Ensure determinations are timely, accurate, documented, and compliant with benefits, clinical criteria, CMS requirements, and company policies.
  • Partner with Medical Directors on complex cases, peer-to-peer reviews, and physician-review cases.
  • Oversee vendor contracting, implementation, delegation, performance, turnaround times, productivity, and quality.
  • Maintain UM policies, procedures, prior authorization lists, and job aids.
  • Improve workflows, automation, and member and provider experiences.
  • Collaborate with Appeals and Grievances, Care Management, Claims, Provider Relations, Compliance, and Product teams.
  • Support regulatory audits, accreditation activities, and quality improvement initiatives.

Requirements

  • Active, unrestricted RN license.
  • BSN or equivalent relevant experience.
  • At least 5 years of clinical nursing experience and 3 years in health plan, managed care, or utilization management settings.
  • Experience leading, supervising, or mentoring clinical staff.
  • Strong coaching, communication, critical-thinking, and conflict-resolution skills.
  • Knowledge of medical-necessity review, clinical documentation, InterQual or MCG criteria, Medicare Advantage, and CMS requirements.
  • Ability to manage competing priorities and regulatory turnaround times.
  • Proficiency with clinical review platforms, electronic health records, and productivity tools.
  • Preferred: Multistate or compact RN license and formal people-management experience in health plan or managed care.
  • Preferred: Case management, UM, or healthcare quality certification; experience with audits, accreditation, delegated vendor oversight, performance improvement, value-based care, or technology-enabled workflows.

Benefits

  • Base salary range of $100,000–$130,000 USD, plus equity opportunities and performance-based bonus.
  • 401(k) matching and regular compensation reviews.
  • Comprehensive medical, dental, and vision coverage.
  • Remote-first culture, flexible time off, No-Meeting Fridays, and monthly company holidays.
  • Mental health resources and paid parental leave for all new parents.
  • Learning programs, mentorship, professional development funding, and performance feedback.
  • Employee Stock Purchase Plan, office setup reimbursement, and monthly cell phone and internet stipend.

Interested in this position?

Apply directly on the company website

Apply Now

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