Registered Nurse (RN) Medicare Quality Assurance Reviewer

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 a Registered Nurse (RN) Medicare Quality Assurance Reviewer, you will:

• Provide clinical expertise support for Clover vendors and Medical Directors.
• Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors.
• Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations.
• Service line clinical reviews.
• Clinical Medical Record Review Subject Matter Expert (SME).
• Identifying clinical opportunities for improvement and communicating to upper management.
• Tracking clinical performance and evaluation of vendors medical reviewers.
• Clinical support for new medical review process implementations.
• Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes.
• Displays Flexibility to adjust work based on new challenges or feedback.
• Clinical collaboration with cross-functional departments.

Success in this role looks like:

• By the end of your first 90 days:

  • Build a strong foundation in Clover’s utilization management, quality assurance, and clinical review processes.
  • Develop proficiency in Medicare regulations, clinical review requirements, and Clover’s quality standards.
  • Establish effective working relationships with internal stakeholders, vendors, and Medical Directors.
  • Consistently perform quality assurance reviews with accuracy, sound clinical judgment, and attention to compliance requirements.

  By 6 months:

  • Independently manage quality assurance responsibilities across utilization management service lines.
  • Serve as a reliable clinical resource for quality, compliance, and review-related questions.
  • Contribute to process improvements by identifying opportunities to enhance quality, consistency, and operational effectiveness.
  • Partner effectively with vendors, Medical Directors, and cross-functional teams to support quality outcomes and regulatory compliance.

  Future state:

  • Be recognized as a trusted clinical quality and utilization management subject matter expert.
  • Drive continuous improvement through trend analysis, performance insights, and recommendations that strengthen quality and compliance programs.
  • Support the evolution of clinical review processes, technology-enabled solutions, and operational initiatives that improve efficiency and member outcomes.
  • Influence organizational success by maintaining high standards of clinical excellence, regulatory compliance, and collaborative partnership across the organization.

You should get in touch if:

• You have an active and valid RN license; required.
• You have a minimum of 3 years of Medicare Utilization Management medical necessity review experience; required.
• You have a strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required.
• You have experience working in a Medicare Advantage plan; preferred
• You have Quality Assurance experience; required.
• You have RN clinical experience in a hospital setting; preferred.
• You have previous experience in leading vendor relationships and building clinical review teams.
• You have excellent interpersonal skills and ability to communicate with patients and colleagues.
• You have experience working remotely; preferred.

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.

Originally posted on Himalayas