Senior Clinical/Operations Internal Monitoring Manager

The posting, as Clover Health wrote it

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), a

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pment 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

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 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:
$129,200 — $168,000 USD