Lead RN, Utilization Management
在 Clover Health,我们致力于为美国老年人提供高质量的，经济实惠且易懂的医疗保健计划。我们优先考虑预防性护理，同时利用数据和技术通过 Clover 助手，这是一种强大的工具，帮助医生做出知情健康建议。通过给医生一个整体的视图每个成员的完整健康史，我们确保更好的护理以低成本向最需要的人提供最高价值。使用管理团队在支持 Clover 成员整个护理旅程中发挥着重要作用。团队由经验丰富的临床医生组成，他们将临床专业知识与数据驱动的见解结合在一起以支持基于证据的决策。与提供商和护理合作伙伴密切合作，UM 团队确保护理转型是流，高效的，并且始终集中在改善成员结果，同时保持遵守 CMS 指南。作为首席 RN,利用管理，你将培训和发展临床工作人员，监督日常审查运作，并监测质量和供应商绩效。你将与 Clover 的医学董事和团队合作，加强审核一致性和改进工作流程。理想的候选人带来了良好的临床判断，强大的领导能力和承诺将成员放在首位。**作为领先 RN,利用管理，你会：** - 领导，教练，以及机上使用管理护士和临床审查员；用于支持人员发展和问责制的案例审计和反。- 管理日常工作负载，人员覆盖率，并通过前景，同时和后期评估升级。-确保评论和决定是及时的，准确的，充分记录的，与福利，临床标准，监管要求和 Clover 政策一致。- 合作与医疗主管在复杂的案件，同行审查和需要医生审查的情况下。- 监督供应商承包，实施，绩效和委托；监测趋势，转型时间，生产力和质量，并执行纠正行动。- 维护 UM 政策，程序，先前授权列表和工作辅助；改善工作流程，自动化以及成员和提供者经验。- 与上诉和投诉，关怀管理，索赔，提供商关系，合规性和产品协作；支持监管审计，认可和质量提高。** 在这个角色中成功。
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At 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.
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**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!
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**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.
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#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_](https://e-verify.uscis.gov/esp/media/resourcesContents/E-Verify_Participation_Poster.pdf) _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