Lead RN, Utilization Management
About The Position
Clover Health is committed to providing high-quality, affordable, and easy-to-understand healthcare plans for seniors. The company uses data and technology through the Clover Assistant to help physicians make informed recommendations and improve care value. The Utilization Management team supports members throughout their care journey through clinical expertise and data-driven, evidence-based decision-making. Working with providers and care partners, the team supports smooth care transitions, improved member outcomes, and compliance with CMS guidelines. The Lead RN, Utilization Management coaches and develops clinical staff, oversees daily review operations, and monitors quality and vendor performance. The role partners with Medical Directors and teams across Clover to strengthen review consistency and improve workflows. The position calls for sound clinical judgment, leadership skills, and a member-first approach.
Requirements
- Hold an active, unrestricted RN license.
- Bachelor of Science in Nursing or equivalent relevant experience.
- At least five years of clinical nursing experience and three 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.
- Understand medical-necessity review and clinical documentation; have applied InterQual or MCG criteria and working knowledge of Medicare Advantage and applicable CMS requirements.
- Ability to manage competing priorities and regulatory turnaround times.
- Proficiency with clinical review platforms, electronic health records, and productivity tools.
Nice To Haves
- A multistate or compact RN license.
- Formal people-management experience in a health plan or managed care setting.
- Experience supporting Medicare Advantage members.
- Certification in case management, UM, or healthcare quality.
- Experience with audits, accreditation, delegated vendor oversight, and performance improvement.
- Familiarity with value-based care and technology-enabled workflows.
Responsibilities
- Lead, coach, and onboard Utilization Management nurses and clinical reviewers; use case audits and feedback to support staff development and accountability.
- Manage daily workloads, staffing coverage, and escalations across prospective, concurrent, and retrospective reviews.
- Ensure reviews and determinations are timely, accurate, well documented, and consistent with benefits, clinical criteria, regulatory requirements, and Clover policies.
- Partner with Medical Directors on complex cases, peer-to-peer reviews, and cases requiring physician review.
- Oversee vendor contracting, implementation, performance, and delegation; monitor trends, turnaround times, productivity, and quality, and implement corrective actions.
- Maintain UM policies, procedures, the prior authorization list, and job aids; improve workflows, automation, and the member and provider experience.
- Collaborate with Appeals and Grievances, Care Management, Claims, Provider Relations, Compliance, and Product; support regulatory audits, accreditation, and quality improvement.
Benefits
- Competitive base salary and equity opportunities.
- Performance-based bonus program.
- 401k matching.
- Regular compensation reviews.
- Comprehensive medical, dental, and vision coverage.
- No-Meeting Fridays.
- Monthly company holidays.
- Access to mental health resources.
- Generous flexible time-off policy.
- Remote-first culture.
- Learning programs and mentorship.
- Professional development funding.
- Regular performance feedback and reviews.
- Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.
- Reimbursement for office setup expenses.
- Monthly cell phone and internet stipend.
- Paid parental leave for all new parents.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
