[Hiring] Lead RN, Utilization Management @Clover Health

Role Description

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.

• 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.

Qualifications

• Active, unrestricted RN license.
• Bachelor of Science in Nursing or equivalent relevant experience.
• At least five years of clinical nursing experience and three years in health plan, managed care, or utilization management settings.
• Experience leading, supervising, or mentoring clinical staff and strong coaching, communication, critical-thinking, and conflict-resolution skills.
• Understanding of medical-necessity review and clinical documentation, with applied InterQual or MCG criteria, and working knowledge of Medicare Advantage and applicable CMS requirements.
• Ability to manage competing priorities and regulatory turnaround times; proficient with clinical review platforms, electronic health records, and productivity tools.

Requirements

• A multistate or compact RN license.
• Formal people-management experience in a health plan or managed care setting.
• Experience supporting Medicare Advantage members.
• Certification in case management, UM, or healthcare quality.
• Experience with audits, accreditation, delegated vendor oversight, and performance improvement.
• Familiarity with value-based care and technology-enabled workflows.

Benefits

• Competitive base salary and equity opportunities.
• Performance-based bonus program, 401k matching, and regular compensation reviews.
• Comprehensive medical, dental, and vision coverage.
• No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.
• Remote-first culture that supports collaboration and flexibility.
• Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.
• Reimbursement for office setup expenses.
• Monthly cell phone & internet stipend.
• Paid parental leave for all new parents.
• And much more!