Remote opportunity at
Clover HealthLead RN, Utilization Management
Clover Health operates as a healthcare organization focused on delivering affordable, data-driven insurance plans tailored for seniors, emphasizing preventive measures and customized member support through proprietary…
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About This Role
Clover Health operates as a healthcare organization focused on delivering affordable, data-driven insurance plans tailored for seniors, emphasizing preventive measures and customized member support through proprietary analytics. The Utilization Management group coordinates member care pathways, partnering with physicians to guarantee that medical transitions remain efficient, compliant with CMS standards, and centered on positive health outcomes. In the capacity of Lead RN for Utilization Management, the professional will direct daily review…
Job Description
Clover Health operates as a healthcare organization focused on delivering affordable, data-driven insurance plans tailored for seniors, emphasizing preventive measures and customized member support through proprietary analytics. The Utilization Management group coordinates member care pathways, partnering with physicians to guarantee that medical transitions remain efficient, compliant with CMS standards, and centered on positive health outcomes. In the capacity of Lead RN for Utilization Management, the professional will direct daily review procedures, mentor clinical personnel, and supervise vendor performance metrics while collaborating closely with Medical Directors.
This position fits a clinically grounded leader who enjoys developing nursing teams, translating operational metrics into practical improvements, and applying sound judgment to intricate medical decisions. The role involves managing prospective, concurrent, and retrospective case reviews while updating internal policies and workflows to enhance provider and member experiences. Qualified individuals will help drive adherence to clinical guidelines, support regulatory audits, and work alongside departments such as Claims, Compliance, and Care Management.
Responsibilities
- Manage onboarding, coaching, and performance evaluation for Utilization Management nurses and clinical reviewers
- Oversee daily workloads, staffing levels, and escalations across prospective, concurrent, and retrospective reviews
- Ensure review determinations are timely, accurate, and aligned with organizational policies, benefits, and regulatory standards
- Collaborate with Medical Directors on peer-to-peer reviews, complex cases, and physician-level evaluations
- Monitor vendor contracting, implementation, quality trends, and turnaround times, applying corrective actions when needed
- Maintain prior authorization lists, department policies, procedures, and job aids to streamline workflows
- Coordinate with cross-functional groups including Appeals and Grievances, Claims, Compliance, Product, and Provider Relations
Requirements
- Active and unrestricted RN license
- Minimum of five years of clinical nursing experience
- At least three years of experience within utilization management, managed care, or health plan settings
- Demonstrated background in supervising, mentoring, or leading clinical staff
- Familiarity with medical-necessity review, clinical documentation, and InterQual or MCG criteria
- Working knowledge of Medicare Advantage rules and applicable CMS requirements
- Proficiency with electronic health records, clinical review software, and productivity tools
Qualifications
- Bachelor of Science in Nursing or equivalent relevant experience
- Multistate or compact RN license
- Formal people-management experience inside a health plan or managed care organization
- Prior experience supporting Medicare Advantage members
- Professional certification in utilization management, case management, or healthcare quality
- Background in regulatory audits, accreditation, delegated vendor oversight, and performance improvement
- Familiarity with value-based care models and technology-enabled clinical workflows
Core Skills
Benefits
- Competitive base salary with equity opportunities and performance-based bonuses
- 401(k) matching program and regular compensation reviews
- Comprehensive medical, dental, and vision insurance coverage
- Flexible time-off policy, monthly company holidays, and No-Meeting Fridays
- Remote-first work culture supporting collaboration from any location
- Employee Stock Purchase Plan providing discounted equity opportunities
- Reimbursement for office setup expenses
- Monthly cell phone and internet stipend
- Paid parental leave for all new parents
- Learning programs, mentorship, and professional development funding
Frequently Asked Questions
Answers are based only on the employer’s listing; where it doesn’t say, neither do we.
What is the salary range for the Lead RN, Utilization Management position?
The base salary range for this role is estimated between $100,000 and $130,000 per year, determined by factors such as market data, internal equity, and the applicant's experience and education.
Is this position remote?
Yes, the source posting indicates a remote-first culture that allows team members to work from any location.
What level of experience is required for this role?
Candidates must have at least five years of clinical nursing experience, with a minimum of three years specifically in a health plan, managed care, or utilization management environment, plus prior experience leading or mentoring clinical staff.
What certifications or educational background are preferred?
A Bachelor of Science in Nursing or equivalent experience is required. Preferred qualifications include certifications in case management, UM, or healthcare quality, along with a multistate or compact RN license.
Sample Interview Questions
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