Senior Clinical/Operations Internal Monitoring Manager

Job not on LinkedIn

🔥 32 minutes ago

🇺🇸 United States – Remote

💵 $129.2k - $168k / year

⏰ Full Time

🟠 Senior

🏥 Clinical Operations

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🏥 Healthcare

🛡️ Insurance

🤖 Artificial Intelligence

Healthcare • Insurance • Artificial Intelligence

Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.

📋 Description

• Lead and oversee second-level auditor monitoring across Utilization Management, Claims, and Appeals & Grievances • Conduct clinical evaluations for Utilization Management and clinical appeals • Direct second-level clinical reviews to evaluate auditor decision-making accuracy, clinical hierarchy compliance, medical policies, and evidence-based guidelines • Lead monitoring programs to verify processing accuracy, regulatory alignment, and operating controls, including SOX Claims QA Control testing • Lead, coach, and develop the Internal Monitoring team • Set priorities and performance expectations, allocate work, manage accountability, and build team capabilities • Analyze monitoring findings and data trends, identify root causes, and oversee remediation plans • Assess internal controls, clinical decision-making protocols, SOPs, and regulatory guidance • Prepare and present monthly quality performance and monitoring reports • Collaborate with processing teams, business leaders, Compliance, and BPaaS partners on remediation and risk mitigation • Support quality projects and conduct focused quarterly audits based on emerging clinical risks • Identify clinical gaps and support tailored training and refresher sessions • Develop and maintain monitoring tools, playbooks, SOPs, audit workbooks, and audit-readiness documentation • Contribute to CMS Program Audit preparation, mock audits, audit data universe validation, and regulatory compliance initiatives • Leverage AI-driven audit tools, machine learning analytics, and automated reporting workflows • Help set the Internal Monitoring function’s 6–12 month strategy, priorities, capacity, and operating approach

🎯 Requirements

• Active, unencumbered Registered Nurse (RN) license required • Minimum of 3+ years of direct experience in internal monitoring, clinical quality oversight, or compliance auditing within a Medicare Advantage health plan • Demonstrated experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and Medicare Advantage operational guidelines • Knowledge of the MCG clinical decision-making tool highly desirable • Proven capability to influence cross-functional clinical teams and collaborate effectively with BPaaS vendors • Demonstrated experience leading and developing teams, including setting priorities, managing performance, coaching employees, allocating capacity, and building team capability across complex or regulated operations • Exceptional project management, prioritization, and organizational skills • Strong analytical and conceptual capabilities for anticipating risks, evaluating clinical process gaps, performing root-cause analysis, and implementing forward-looking solutions • Meticulous attention to detail with excellent documentation, verbal/written communication, and systems skills • Ability to drive results independently while fostering a positive, team-oriented environment • Ability to remain current on processes, regulatory guidance, and company policies • Ability to work under pressure to meet tight regulatory and audit deadlines • Flexibility to support peak operational or audit periods

🏖️ Benefits

• Competitive base salary • Equity opportunities • Performance-based bonus program • 401k matching • Regular compensation reviews • Comprehensive medical, dental, and vision coverage • No-Meeting Fridays • Monthly company holidays • Mental health resources • Generous flexible time-off policy • Remote-first culture supporting collaboration and flexibility • Learning programs • 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 & internet stipend • Collaboration with global teams • Paid parental leave for all new parents

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