Lead RN, Utilization Management

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 regulatory audits, accreditation, and quality improvement.

Success in this role looks like

• You enjoy developing others and helping clinical teams deliver consistent, high-quality work.
• You use data to improve care operations and turn performance trends into practical solutions.
• You put members first and bring sound clinical judgment, clear communication, and collaboration to complex decisions.

You should get in touch if

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

Preferred

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

A reasonable estimate of the base salary range for this role is

$100,000—$130,000 USD