Senior Clinical/Operations Internal Monitoring Manager

Clover Health

12d•$129,200 - $168,000•Remote

About The Position

The Senior Manager of Internal Monitoring leads second-level monitoring across Clover’s ODAG functions, including Utilization Management (UM), Claims, and Appeals & Grievances. The role ensures operational compliance and alignment with regulatory standards and company policies, and provides direct clinical monitoring by conducting evaluations of UM and clinical appeals for sound, high-quality clinical decision-making. The position leads the Internal Monitoring function across clinical and non-clinical monitoring, helping set the 6–12 month strategy, priorities, capacity, and operating approach. It leads and develops the monitoring team and aligns people, processes, and capabilities with evolving regulatory and business risks. Responsibilities also include risk-based audits, operating-control assessments, clinical hierarchy alignment, quality and root-cause analysis, executive reporting, remediation oversight, and process optimization using artificial intelligence. The Senior Manager works with internal business leaders, Compliance, processing teams, and BPaaS partners to identify and address operational risks. The role supports CMS Program Audit preparation and related initiatives, maintains monitoring documentation and tools, and uses AI-driven audit tools, machine-learning analytics, and automated reporting workflows to improve sampling, risk detection, accuracy, and scalability. Clover describes itself as a mission-driven health insurance company that combines data, custom software, analytics, and human empathy to provide personalized care. The company emphasizes diversity and inclusion and operates a remote-first culture.

Requirements

Active, unencumbered Registered Nurse (RN) license.
At least 3 years of direct experience in internal monitoring, clinical quality oversight, or compliance auditing within a Medicare Advantage health plan.
Experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and Medicare Advantage operational guidelines.
Ability to influence cross-functional clinical teams and collaborate effectively with BPaaS vendors.
Experience leading and developing teams, including setting priorities, managing performance, coaching employees, allocating capacity, and building team capability in complex or regulated operations.
Strong project management, prioritization, and organizational skills, including the ability to navigate complex clinical priorities in a fast-paced environment.
Strong analytical and conceptual capabilities to anticipate risks, evaluate clinical process gaps, perform root-cause analysis, and implement forward-looking solutions.
Attention to detail and strong documentation, verbal and written communication, and systems skills for preparing reports and communicating risks.
Ability to drive results independently while fostering a positive, team-oriented environment and staying current on processes, regulatory guidance, and company policies.
Ability to work under pressure to meet regulatory and audit deadlines, with flexibility to support peak operational or audit periods.

Nice To Haves

Knowledge of the MCG clinical decision-making tool.

Responsibilities

Direct and perform second-level clinical reviews across Utilization Management and Clinical Appeals to assess auditor decision accuracy, compliance with clinical hierarchy, and adherence to medical policies and evidence-based guidelines.
Lead second-level monitoring programs across UM, Claims, and Appeals & Grievances to verify processing accuracy, regulatory alignment, and key operating controls, including Sarbanes-Oxley Claims QA Control testing.
Lead, coach, and develop team members responsible for clinical and non-clinical monitoring; set priorities and performance expectations, allocate work based on risk and capacity, and hold the team accountable for quality and outcomes.
Help establish the Internal Monitoring function’s 6–12 month strategy, priorities, capacity, and operating approach.
Analyze monitoring findings and trends to identify root causes, clinical improvement opportunities, and process vulnerabilities, and oversee remediation plans.
Conduct deep-dive reviews to assess the adequacy and effectiveness of internal controls, clinical decision-making protocols, standard operating procedures, and regulatory guidance.
Prepare and present monthly quality performance and monitoring reports to operational leaders, BPaaS and business partners, and Compliance, including customer impact analysis and recommendations.
Partner with processing teams, business leaders, Compliance, and BPaaS partners to design remediation strategies, track errors through remediation, and validate outcomes through focused post-remediation reviews.
Support quality projects, maintain monitoring tools, expand clinical quality monitoring, and initiate focused quarterly audits based on emerging clinical risks.
Identify clinical gaps requiring intervention and work with business teams to develop plans, tailored training materials, and refresher sessions.
Develop, standardize, and maintain ODAG Monitoring tools and Playbooks, SOPs, audit workbooks, and audit-readiness documentation.
Contribute to CMS Program Audit preparation, mock audits, ODAG audit data universe validation, and regulatory decision-making protocol compliance initiatives.
Use AI-driven audit tools, machine-learning analytics, and automated reporting workflows to optimize sampling, detect emerging compliance risks, and improve monitoring accuracy and scalability.