Lead RN, Utilization Management
New
C
Clover HealthHealth insurance
Remote - USAFull-TimeLead
SalaryA reasonable estimate of the base salary range for this role is: $100,000 — $130,000 USD
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Job Details
- Experience
- At least five years of clinical nursing experience and three years in health plan, managed care, or utilization management settings.
- Required Skills
- EHR
Requirements
- Hold an active, unrestricted RN license.
- Have a Bachelor of Science in Nursing or equivalent relevant experience.
- Have at least five years of clinical nursing experience.
- Have three years of experience in health plan, managed care, or utilization management settings.
- Have experience leading, supervising, or mentoring clinical staff.
- Bring coaching, communication, critical-thinking, and conflict-resolution skills.
- Understand medical-necessity review and clinical documentation.
- Have applied InterQual or MCG criteria.
- Have working knowledge of Medicare Advantage and applicable CMS requirements.
- Be able to manage competing priorities and regulatory turnaround times.
- Be proficient with clinical review platforms, electronic health records, and productivity tools.
- Preferred: multistate or compact RN license, formal people-management experience in a health plan or managed care setting, and experience supporting Medicare Advantage members.
- Preferred: certification in case management, UM, or healthcare quality; experience with audits, accreditation, delegated vendor oversight, and performance improvement; and 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.
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