Senior RN, Utilization Management — Remote Leadership

Clover Health; United States; A distancia; USD 100.000 - 130.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote-first culture

Performance-based bonus

401k matching

Regular compensation reviews

ESPP

Stipend for cell phone & internet

Paid parental leave

Descripción de la vacante

Clover Health is seeking a Lead RN, Utilization Management, to coach clinical staff, oversee daily review operations, and ensure timely, accurate determinations that align with benefits, clinical criteria, and CMS requirements. You will partner with Medical Directors and teams across Clover to strengthen review consistency and improve workflows.

The ideal candidate holds an active RN license and a BSN (or equivalent), with at least five years of clinical nursing experience and three years in

Formación

• Active, unrestricted RN license.
• BSN or equivalent nursing degree.
• 5+ years of clinical nursing experience; 3+ years in health plan/utilization management.
• Experience leading staff; strong coaching and communication skills.
• Familiarity with Medicare Advantage criteria and CMS requirements.

Responsabilidades

• Lead, coach, and onboard Utilization Management nurses and reviewers; use audits/feedback for staff development.
• Manage daily workloads, staffing coverage, and escalations across prospective, concurrent, and retrospective reviews.
• Ensure reviews/determinations are timely, accurate, and well-documented per benefits and regulatory requirements.
• Partner with Medical Directors on complex cases and peer-to-peer reviews.
• Oversee vendor contracting, performance, and delegation; monitor trends and quality; implement corrective actions.
• Maintain UM policies and workflows; improve automation and member/provider experience.
• Collaborate with Appeals, Care Management, Claims, Provider Relations, Compliance, and Product; support audits and accreditation.

Conocimientos

RN license

Leadership

Coaching

Clinical review

CMS criteria

Educación

BSN

Herramientas

EHR systems

InterQual/MCG

Descripción del empleo

Clover Health is seeking a Lead RN, Utilization Management, to coach clinical staff, oversee daily review operations, and ensure timely, accurate determinations that align with benefits, clinical criteria, and CMS requirements. You will partner with Medical Directors and teams across Clover to strengthen review consistency and improve workflows.

The ideal candidate holds an active RN license and a BSN (or equivalent), with at least five years of clinical nursing experience and three years in