Lead RN, Utilization Management

Job description

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 regula…