Utilization Review/Prior Auth · Lead RN, Utilization Management

Jemma LLC; United States; Remote; USD 100,000 - 130,000; Full time

Benefits offered by this job

Health insurance

Remote-first culture

401k matching

Cell phone stipend

Employee stock purchase plan

Job summary

Clover Health is seeking a Lead RN, Utilization Management, to coach and onboard UM nurses, oversee daily review operations, and align reviews with benefits, clinical criteria, regulatory requirements, and Clover policies.

You will partner with Medical Directors to improve workflows and ensure timely, accurate determinations while maintaining a member-first focus.

Qualifications

• Bachelor of Science in Nursing or equivalent relevant experience.
• Active, unrestricted RN license.
• At least five years of clinical nursing experience and three years in health plan, managed care, or utilization management.
• Experience leading, supervising, or mentoring clinical staff.
• Experience with medical-necessity review and clinical documentation; familiarity with InterQual/MCG criteria and CMS requirements.

Responsibilities

• Lead, coach, and onboard Utilization Management nurses and clinical reviewers; use case audits and feedback to support staff development.
• Manage daily workloads, staffing coverage, and escalations across prospective, concurrent, and retrospective reviews.
• Ensure reviews and determinations are timely, accurate, and well documented.
• Partner with Medical Directors on complex cases and peer-to-peer reviews.
• Oversee vendor contracting, performance, and delegation; monitor trends and productivity.

Skills

Leadership

Coaching

Clinical nursing

Regulatory knowledge

CMS requirements

Education

Bachelor of Science in Nursing (BSN) or equivalent

Job description

# Lead RN, Utilization ManagementClover Health · Remote · Posted todayRNUtilization Review/Prior AuthRemoteApply on employer site →Applications happen on the employer's own careers site — Jemma never handles your application.Employer-stated range: $100K–$130K/yr What verified nurses actually earn in this role — visible to verified members.Create a free account →## About this roleAt Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most.The Utilization Management (UM) team plays a vital role in supporting Clover members throughout their care journey. The team is made up of experienced clinicians who combine clinical expertise with data-driven insights to support evidence-based decision-making. Working closely with providers and care partners, the UM team ensures that care transitions are smooth, efficient, and always focused on improving member outcomes while maintaining compliance with CMS guidelines.As the Lead RN, Utilization Management, you will coach and develop clinical staff, oversee daily review operations, and monitor quality and vendor performance. You will partner with Medical Directors and teams across Clover to strengthen review consistency and improve workflows. The ideal candidate brings sound clinical judgment, strong leadership skills, and a commitment to putting members first.**As a Lead RN, Utilization Management, you will:*** 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.**Success in this role looks like:*** **You enjoy developing others** and helping clinical teams deliver consistent, high-quality work.* **You use data to improve care operations** and turn performance trends into practical solutions.* **You put members first** and bring sound clinical judgment, clear communication, and collaboration to complex decisions.**You should get in touch if:*** You hold an active, unrestricted RN license* Bachelor of Science in Nursing or equivalent relevant experience.* You have at least five years of clinical nursing experience and three years in health plan, managed care, or utilization management settings.* You have experience leading, supervising, or mentoring clinical staff and strong coaching, communication, critical-thinking, and conflict-resolution skills.* You understand medical-necessity review and clinical documentation, have applied InterQual or MCG criteria, and have working knowledge of Medicare Advantage and applicable CMS requirements.* You can manage competing priorities and regulatory turnaround times and are proficient with clinical review platforms, electronic health records, and productivity tools. **Preferred:** A multistate or compact RN license; formal people-management experience in a health plan or managed care setting; and experience supporting Medicare Advantage members. 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.**Benefits Overview**:* **Financial Well-Being**: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.* **Physical Well-Being**: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.* **Mental Well-Being**: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.* **Professional Development**: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.*Additional Perks:** Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities* Reimbursement for office setup expenses* Monthly cell phone & internet stipend* Remote-first culture, enabling collaboration with global teams* Paid parental leave for all new parents* And much more!\\*\\*About Clover: \\*\\*We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.#LI-REMOTE / #LI-ONSITE / #LI-HYBRID*Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an* \\_ **E-Verify* \\_ company.*Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.A reasonable estimate of the base salary range for this role is:$100,000 — $130,000 USD