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. This role provides direct clinical monitoring leadership by conducting clinical evaluations for UM and clinical appeals, conducts risk-based operational audits, drives process optimization through Artificial Intelligence (AI) integration, and leads and develops the Internal Monitoring team across clinical and non-clinical second-level monitoring.

Responsibilities

Direct and perform second-level clinical reviews across Utilization Management (UM) and Clinical Appeals; Lead second-level monitoring programs across ODAG operational areas (UM, Claims, and Appeals & Grievances), including Sarbanes-Oxley (SOX) Claims QA Control testing; Lead, coach, and develop the Internal Monitoring team; Analyze monitoring findings and data trends to identify root causes and oversee remediation plans; Execute deep-dive clinical monitoring reviews to test internal controls, clinical decision-making protocols, and SOPs; Prepare and present monthly quality performance and monitoring reports to operational leaders, BPaaS partners, and compliance; Partner with processing teams, business leaders, Compliance, and BPaaS partners to design remediation strategies and validate results; Support quality projects, maintain monitoring tools, and initiate focused quarterly audits; Identify clinical gaps and support training and intervention plans; Develop and maintain ODAG Monitoring tools, Playbooks, SOPs, audit workbooks, and audit readiness documentation; Serve as a key contributor to CMS Program Audit preparation, mock audits, and ODAG audit data universe validation; Leverage AI-driven audit tools and analytics to optimize sampling and detect compliance risks; Help set the 6-12 month strategy, priorities, capacity, and operating approach for the Internal Monitoring function

Requirements

Active, unencumbered Registered Nurse (RN) license; Minimum of 3+ years of direct experience in internal monitoring, clinical quality oversight, or compliance auditing within a Medicare Advantage health plan; Demonstrated experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and Medicare Advantage operational guidelines; Proven capability to influence cross-functional clinical teams and collaborate effectively with BPaaS vendors; Demonstrated experience leading and developing teams, including setting priorities, managing performance, coaching employees, allocating capacity, and building team capability; Exceptional project management, prioritization, and organizational skills; Strong analytical and conceptual capabilities, including root-cause analysis; Meticulous attention to detail with excellent documentation, verbal/written communication, and systems skills; Self-directed, with the ability to drive results independently and remain current on regulatory guidance and company policies; Ability to thrive under pressure to meet tight regulatory and audit deadlines, with flexibility to support peak periods

Nice to have

Knowledge of the MCG clinical decision-making tool; Experience with Artificial Intelligence (AI)-driven audit tools, machine learning analytics, or automated reporting workflows

Benefits

Competitive base salary and equity opportunities; Performance-based bonus program; 401k matching; Regular compensation reviews; Comprehensive medical, dental, and vision coverage; No-Meeting Fridays; Monthly company holidays; Access to mental health resources; Generous flexible time-off policy; Remote-first culture; Learning programs, mentorship, and professional development funding; Regular performance feedback and reviews; Employee Stock Purchase Plan (ESPP); Reimbursement for office setup expenses; Monthly cell phone and internet stipend; Paid parental leave for all new parents