Senior Clinical/Operations Internal Monitoring Manager

The Senior Manager of Internal Monitoring plays a pivotal role in leading and overseeing second-level auditor monitoring across all ODAG functions—including Utilization Management (UM), Claims, and Appeals & Grievances—to ensure operational compliance and alignment with regulatory standards and Clover policies.

Specifically, this role provides direct clinical monitoring leadership by conducting clinical evaluations for UM and clinical appeals to guarantee high-quality, sound clinical decision-making. In addition to guiding monitoring workflows and evaluating operating controls, the Senior Manager conducts risk-based operational audits, assesses alignment with clinical hierarchy, and drives process optimization through Artificial Intelligence (AI) integration. The Senior Manager also analyzes quality trends and root causes, delivers executive performance reporting, and collaborates cross-functionally with internal business leaders and BPaaS partners to resolve operational risks and execute effective remediation strategies. This role is also accountable for leading the Internal Monitoring function across clinical and non-clinical second-level monitoring, including helping to set the 6-12 month strategy, priorities, capacity, and operating approach. The Senior Manager leads and develops the Internal Monitoring team and ensures people, processes, and monitoring capabilities are aligned to evolving regulatory and business risks.

As a Senior Cinical/Operations Internal Monitoring Manager, you will:

• Clinical Monitoring (UM & Clinical Appeals): Direct and perform second-level clinical reviews across Utilization Management (UM) and Clinical Appeals to evaluate auditor decision-making accuracy, compliance with clinical hierarchy, and adherence to medical policies and evidence-based guidelines.
• ODAG Second-Level Monitoring Management: Lead second-level monitoring programs encompassing all ODAG operational areas (UM, Claims, and Appeals & Grievances) to verify processing accuracy, maintain regulatory alignment, and evaluate key operating controls, including Sarbanes-Oxley (SOX) Claims QA Control testing.
• Lead and Develop the Internal Monitoring Team: Lead, coach, and develop team members responsible for clinical and non-clinical monitoring across ODAG functions. Set clear priorities and performance expectations, allocate work based on regulatory risk and capacity, hold team members accountable for quality and outcomes, and build the capabilities needed to deliver sustained monitoring effectiveness.
• Audit Analysis & Corrective Action: Analyze monitoring findings and data trends to identify root causes, uncover clinical improvement opportunities and process vulnerabilities, and oversee actionable remediation plans.
• Controls & Governance Assessment: Execute deep-dive clinical monitoring reviews to test the adequacy, effectiveness, and strength of internal controls, clinical decision-making protocols, standard operating procedures (SOPs), and regulatory guidance.
• Reporting & Stakeholder Engagement: Prepare and present comprehensive monthly quality performance and monitoring reports to key operational leaders, BPaaS and business partners, and compliance providing clear feedback, customer impact analysis, and actionable recommendations.
• Remediation & Risk Mitigation: Partner with processing teams, business leaders, Compliance, and BPaaS partners to design effective remediation strategies, follow monitoring errors through remediation, and validate results through focused post-remediation reviews.
• Quality Management & Focused Projects: Support quality projects and maintain monitoring tools to expand clinical quality monitoring, initiating focused quarterly audits based on emerging clinical risks.
• Training & Intervention: Identify critical clinical gaps requiring monitoring intervention. Work with business teams to support development of plans, tailored training materials, and refresher sessions to promote improved decision-making performance.
• Documentation: Develop, standardize, and maintain comprehensive ODAG Monitoring tools and Playbooks, standard operating procedures (SOPs), audit workbooks, and audit readiness documentation to safeguard operational consistency and support Compliance Business Continuity.
• CMS Regulatory & Audit Support: Serve as a key contributor to CMS Program Audit preparation, mock audits, ODAG audit data universe validation, and regulatory decision-making protocol compliance initiatives.
• Artificial Intelligence (AI) Integration: Leverage AI-driven audit tools, machine learning analytics, and automated reporting workflows to optimize sampling methodologies, detect emerging compliance risks, and elevate the accuracy and scalability of clinical monitoring operations.

You should get in touch if:

• You have active, unencumbered Registered Nurse (RN) license required.
• You have minimum of 3+ years of direct experience in internal monitoring, clinical quality oversight, compliance auditing within a Medicare Advantage health plan.
• You have a demonstrated experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and Medicare Advantage operational guidelines. Knowledge of the MCG clinical decision-making tool is highly desirable.
• You have a proven capability to influence cross-functional clinical teams and collaborate effectively with BPaaS vendors.
• You have a demonstrated experience leading and developing teams, including setting priorities, managing performance, coaching employees, allocating capacity, and building team capability across complex or regulated operations.
• You have exceptional project management, prioritization, and organizational skills with the ability to navigate complex clinical priorities in a fast-paced environment.
• You have strong analytical and conceptual capabilities to anticipate risks, evaluate clinical process gaps, perform root-cause analysis, and implement forward-looking solutions before issues escalate.
• You have meticulous attention to detail with excellent documentation, verbal/written communication, and systems skills for preparing reports and communicating risks to business partners.
• You have self-directed professional capable of driving results independently while fostering a positive, team-oriented environment and remaining current on process, regulatory guidance, and company policies.
• You thrive under pressure to meet tight regulatory and audit deadlines, with flexibility to support peak operational or audit periods.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
• Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.

Additional Perks:

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for all new parents
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are anE-Verify company.

Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.

Originally posted on Himalayas