Senior Clinical/Operations Internal Monitoring Manager

The role

The Senior Manager of Internal Monitoring leads second-level auditor monitoring across ODAG functions to ensure regulatory compliance. This role conducts clinical evaluations for UM and clinical appeals and manages the Internal Monitoring team.

What you will do

• Direct and perform second-level clinical reviews across Utilization Management and Clinical Appeals
• Lead second-level monitoring programs for UM, Claims, and Appeals & Grievances
• Lead, coach, and develop the Internal Monitoring team
• Analyze monitoring findings and data trends to identify root causes
• Execute deep-dive clinical monitoring reviews to test internal controls
• Prepare and present monthly quality performance and monitoring reports
• Partner with processing teams and business leaders to design remediation strategies
• Support quality projects and maintain monitoring tools
• Identify critical clinical gaps requiring monitoring intervention
• Develop, standardize, and maintain ODAG Monitoring tools and Playbooks

Required qualifications

• Active, unencumbered Registered Nurse (RN) license
• Minimum of 3+ years of direct experience in internal monitoring, clinical quality oversight, or compliance auditing within a Medicare Advantage health plan
• Experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and Medicare Advantage operational guidelines
• Capability to influence cross-functional clinical teams and collaborate with BPaaS vendors
• Experience leading and developing teams, including setting priorities, managing performance, and coaching employees
• Project management, prioritization, and organizational skills
• Analytical and conceptual capabilities to evaluate clinical process gaps and perform root-cause analysis
• Attention to detail with documentation, verbal/written communication, and systems skills

Nice to have

• Knowledge of the MCG clinical decision-making tool

Benefits

• Competitive base salary
• Equity opportunities
• Performance-based bonus program
• 401k matching
• Regular compensation reviews
• Medical, dental, and vision coverage
• No-Meeting Fridays
• Monthly company holidays
• Access to mental health resources
• Flexible time-off policy
• Learning programs, mentorship, and professional development funding
• Employee Stock Purchase Plan (ESPP)

About the company

Clover is reinventing health insurance by combining the power of data with human empathy to keep members healthier. They use custom software and analytics to empower clinical staff to provide personalized care.