About the role
Clover Health is hiring a remote Lead RN for its Utilization Management team. You'll coach and onboard UM nurses and clinical reviewers, run daily workloads across prospective, concurrent, and retrospective reviews, and make sure determinations are timely and compliant. An active, unrestricted RN license is required, and a multistate (compact) license is a plus.
Responsibilities
- Lead, coach, and onboard UM nurses and clinical reviewers using case audits and feedback
- Manage daily workloads, staffing coverage, and escalations across prospective, concurrent, and retrospective reviews
- Make sure determinations are timely, accurate, and well documented under benefits, clinical criteria, and regulations
- Work with Medical Directors on complex cases and peer-to-peer reviews
- Oversee vendor contracting, performance, and delegation and drive corrective actions
- Maintain UM policies, procedures, the prior authorization list, and job aids
- Partner with Appeals and Grievances, Care Management, Claims, Provider Relations, Compliance, and Product
Requirements
- Active, unrestricted RN license; multistate/compact (NLC) license preferred
- BSN or equivalent relevant experience
- At least 5 years of clinical nursing experience
- At least 3 years in a health plan, managed care, or UM setting
- Experience leading, supervising, or mentoring clinical staff
- Familiarity with medical-necessity review and InterQual or MCG criteria
- Working knowledge of Medicare Advantage and CMS requirements
- Preferred: formal people-management experience, Medicare Advantage experience, case management/UM/quality certification, audit and delegated-vendor oversight experience
What we offer
- Base salary plus performance bonus and equity opportunities
- 401(k) matching
- Medical, dental, and vision coverage
- Flexible time off, monthly company holidays, and No-Meeting Fridays
- Monthly phone and internet stipend and office setup reimbursement
- Employee stock purchase plan
- Paid parental leave and professional development funding