[All remote jobs](https://jobicy.com/jobs.md)[![Clover Health logo](https://jobicy.com/data/server-nyc0409/galaxy/mercury/2025/06/8d4e74b3-221.jpg)](https://jobicy.com/company/clover-health.md)[Clover Health](https://jobicy.com/company/clover-health.md) # Lead RN, Utilization Management Review the role, location requirements, compensation details, and application process before deciding whether this opportunity fits your next career move. [Apply for this job](#job-application)[View company](https://jobicy.com/company/clover-health.md)ShareRemote from[USA](https://jobicy.com/job-region/usa.md)SalaryUSD 100k–130k / yrDepartment[Healthcare & Medical](https://jobicy.com/categories/healthcare.md)EmploymentFull TimeExperienceSeniorPublished27 Oct 2026Apply before26 Nov 2026Listing views43Application actions2Application toolkit ## Make your next move. Prepare your resume, explore your fit, and draft a cover letter for this opportunity. AI Summary ## The role, at a glance. Clover Health seeks a Lead RN to oversee utilization-management operations for Medicare Advantage members. The role leads and coaches clinical reviewers, manages daily staffing and escalations, and ensures timely, compliant medical-necessity determinations. It partners with Medical Directors and cross-functional teams while overseeing delegated vendors, audits, quality trends, and workflow improvements. Candidates need an active unrestricted RN license, substantial clinical and managed-care experience, and practical knowledge of InterQual or MCG criteria and CMS requirements. ## Role DNA A quick view of the complexity, pace, ownership and collaboration implied by the job description. ### Job Complexity 4/5EasyHard ### Pace & Pressure 4/5RelaxedFast-paced ### Autonomy Level 4/5GuidedFull ownership ### Communication Load 5/5IndependentCollaborative AI insightThis is a senior clinical-operations leadership role with regulatory deadlines, complex authorization decisions, vendor oversight, and direct accountability for review quality. It requires combining nursing judgment with people leadership and Medicare Advantage compliance expertise. ## Salary analysis Estimated compensation compared with the broader US market for similar roles. Estimated job median (per year)Market rate$115,000US market range (per year)$105k–$140k0$154k AI insightThe yearly pay period is inferred from the job context; it was not explicitly stated by the employer. The employer discloses a credible annual base-salary range of $100,000–$130,000 USD, with a midpoint of $115,000. Estimated US market pay for a lead utilization-management RN is approximately $105,000–$140,000 per year, varying by managed-care leadership scope, licensure, and Medicare Advantage experience. ## Core skills Skills and capabilities most closely associated with this opportunity. [Registered Nursing](https://jobicy.com/jobs?search_keywords=Registered%20Nursing.md)[Utilization Management](https://jobicy.com/jobs?search_keywords=Utilization%20Management.md)[Medicare Advantage](https://jobicy.com/jobs?search_keywords=Medicare%20Advantage.md)[CMS Compliance](https://jobicy.com/jobs?search_keywords=CMS%20Compliance.md)[Medical Necessity Review](https://jobicy.com/jobs?search_keywords=Medical%20Necessity%20Review.md)[InterQual Criteria](https://jobicy.com/jobs?search_keywords=InterQual%20Criteria.md)[MCG Criteria](https://jobicy.com/jobs?search_keywords=MCG%20Criteria.md)[Clinical Documentation](https://jobicy.com/jobs?search_keywords=Clinical%20Documentation.md)[Prior Authorization](https://jobicy.com/jobs?search_keywords=Prior%20Authorization.md)[People Leadership](https://jobicy.com/jobs?search_keywords=People%20Leadership.md)[Clinical Team Coaching](https://jobicy.com/jobs?search_keywords=Clinical%20Team%20Coaching.md)[Vendor Management](https://jobicy.com/jobs?search_keywords=Vendor%20Management.md)[Quality Improvement](https://jobicy.com/jobs?search_keywords=Quality%20Improvement.md)[Case Auditing](https://jobicy.com/jobs?search_keywords=Case%20Auditing.md)[Electronic Health Records](https://jobicy.com/jobs?search_keywords=Electronic%20Health%20Records.md) Sample interview questionsHow do you ensure that utilization-management determinations are clinically sound, timely, and compliant?I use standardized clinical criteria, benefit requirements, and clear documentation standards while monitoring turnaround-time dashboards and audit findings. I escalate cases requiring physician input promptly and use recurring errors or delays to target coaching and process improvements. Describe your approach to coaching UM nurses with varied levels of experience. I set clear expectations, review cases and quality data with each nurse, and provide specific, practical feedback. I combine case-based education with follow-up audits so staff can build confidence while being accountable for measurable improvement. How have you worked with Medical Directors on complex authorization cases? I prepare a concise clinical summary, relevant criteria, member benefits, and the specific decision point requiring physician review. I document the consultation clearly and ensure the final determination and member or provider communications meet required timelines. What metrics would you use to evaluate a delegated UM vendor? I would assess turnaround-time compliance, determination accuracy, denial rationale quality, documentation completeness, productivity, appeals and overturn trends, and audit results. I would review trends regularly, establish corrective-action plans for gaps, and validate that improvements are sustained. How would you improve a UM workflow without compromising regulatory compliance? I would map the current process, identify bottlenecks through operational data and staff feedback, and prioritize changes that reduce rework or manual handoffs. Before implementation, I would validate the workflow against CMS requirements and policies, pilot the change, and monitor quality and turnaround outcomes. Opportunity details ## About this role. 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 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. 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. #LI-REMOTE / #LI-ONSITE / #LI-HYBRID Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an[E-Verify](https://e-verify.uscis.gov/esp/media/resourcesContents/E-Verify_Participation_Poster.pdf) 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. A reasonable estimate of the base salary range for this role is: $100,000—$130,000 USD Show more [Apply now >](https://jobicy.com/jobs/157424-lead-rn-utilization-management.md) * ![Upload CV](data:image/svg+xml;base64,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) ### Upload your resume now To unlock remote work opportunities and be discovered by global employers. 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