Remote Lead RN, Utilization Management

Clover Health; Oregon; Hybrid; USD 100,000 - 130,000; Full time

Benefits offered by this job

ESPP

Office setup reimbursement

Monthly cell phone & internet stipend

Remote-first culture

Paid parental leave

Job summary

Clover Health is seeking a Lead RN, Utilization Management, to coach UM nurses, oversee daily review operations, and monitor quality. You will partner with Medical Directors and Clover teams to strengthen review consistency and improve workflows while ensuring compliance with CMS guidelines.

The role emphasizes leadership, clinical judgment, and member-first decision-making within a remote-friendly environment.

Qualifications

• Active, unrestricted RN license.
• BSN or equivalent nursing degree.
• At least five years of clinical nursing experience and three years in health plan, managed care, or UM settings.
• Experience leading, supervising, or mentoring clinical staff with coaching skills.
• Familiarity with Medicare Advantage and CMS requirements; understanding of medical-necessity reviews.
• Proficient with clinical review platforms, EHRs, and productivity tools.

Responsibilities

• Lead, coach, and onboard Utilization Management nurses and reviewers; use audits and feedback for development.
• Manage daily workloads, staffing, and escalations across prospective, concurrent, and retrospective reviews.
• Ensure timely, accurate reviews aligned with benefits, criteria, regulatory requirements, and Clover policies.
• Collaborate with Medical Directors on complex cases and peer-to-peer reviews.
• Oversee vendor contracting, performance, and delegation; monitor trends and implement improvements.
• Maintain UM policies, prior authorization lists, and improve workflows for member experience.
• Collaborate with Appeals, Care Management, Claims, Provider Relations, Compliance, and Product; support audits and quality improvement.

Skills

RN license

Leadership

Coaching

Communication

Critical thinking

Conflict resolution

CMS requirements familiarity

EHR systems

Clinical review platforms

Education

BSN or equivalent

Tools

InterQual or MCG criteria

EHR systems

Clinical review platforms

Job description

Clover Health is seeking a Lead RN, Utilization Management, to coach UM nurses, oversee daily review operations, and monitor quality. You will partner with Medical Directors and Clover teams to strengthen review consistency and improve workflows while ensuring compliance with CMS guidelines.

The role emphasizes leadership, clinical judgment, and member-first decision-making within a remote-friendly environment.