Utilization Management RN Manager at Clover Health
San Francisco, CA, US
Clover Health is driving down costs and producing improved health outcomes with a unique health insurance plan. We use sophisticated analytics and custom software to direct our own clinical staff to proactively fill in gaps in the care of our members. We have a proven model we're scaling out.

We're focusing on elderly and low-income patients that stand to benefit from our model the most. This puts us in a position to make a major dent in healthcare expense in the United States and reverse an unsustainable, decades-long spending trend.

Job Description:

The UM RN Manager works directly with the Medical Director to coordinate and manage the clinical review team. In addition to staff management, this position is responsible for coordinating care transitions from either direct hospital discharge to the member's home or discharge to another care facility (LTACH, Acute Rehabilitation, Subacute, SNF) and then subsequent discharge to the member's home. The UM RN Manager is responsible for coordinating and performing medical necessity reviews of care facility utilization and services related to the case, medical necessity reviews of Claims, and medical necessity reviews of Appeals. Leading the clinical review team, the UM RN Manager facilitates interdisciplinary collaboration and care continuity across care settings and be responsible for ensuring the development and implementation of effective care transition plans in order to reduce readmissions.

Principal supervisory responsibilities include: Managing the team that may consist of RNs, LPNs, and LCSWs.

Transition of Care:

Lead team efforts to implement the Care Transition Intervention; empowering members to take an active role in their healthcare by providing knowledge, tools and support to foster self-management and to successfully respond to common problems that arise during transitions from one healthcare setting to another.
Collaborate with the hospital, care facility, case management and PCPs to effect transition of care plans in order to reduce hospital readmissions.
Screen for high risk of readmission; consult with Medical Director to anticipate and prevent readmissions and/or inappropriate ER use and collaborate on the Care Transitions Discharge Plan.
Evaluate and seek continuous quality improvement of Care Transitions discharge plans produced by staff.
Ensure staff learning and practice of the guiding principles and practical strategies of Motivational Interviewing with patient and family caregiver.
Work with staff to systematically assess member baseline activation level for self-care.

Care Facility Concurrent Review:

Ensure the timely medical necessity concurrent review of care facility utilization by members and facility.
Work with the Medical Director to validate patient acuity, plan of care and medical necessity review recommendations.
Ensure the efficient transition of members from hospital to care facility to reduce and eliminate unnecessary hospital days; coordinate with care facility admitting, attending, PCP, case manager, social workers, and other liaisons regarding the patient’s acuity level and plan of care.
Establish and leverage relationships with contracted hospitals, care facilities and providers to ensure the needs of the members are met and policies of the plan are followed.
Coordinate care facility to member domicile care transitions to reduce readmissions.


With the the medical management leadership, collaborate in implementing and monitoring departmental strategic plans for utilization management and care coordination; conduct ongoing analysis that results in department changes to boost efficiency and effectiveness and align work processes with department goals and objectives.
Monitor and evaluate transition of care interventions for relevancy, timeliness, and effectiveness.
Develop and oversee systems for case load assignments, productivity metrics and meaningful management reports of both activities and outcomes. This will include analysis and reporting on utilization, health outcomes, care coordination and expenses with comparison to state and national standards and benchmarks.
Assure staff and department compliance with all regulatory, contractual and accreditation requirements and provide documentation for audits.

Desired Skills, Experience, and Education:

Effective interpersonal skills
Strong organizational skills, the ability to multitask in a constantly changing environment.
Computer proficiency including the ability to type and talk at the same time, and navigating an Apple Mac environment required
2-3 years experience in a hospital setting, acute care, direct care experience preferred OR experience as case manager, care coordinator, concurrent review nurse, utilization review nurse, or discharge planner preferred
Prior experience with EMRs, case management, utilization/concurrent review, prior authorization, care coordination, & discharge planning software tools preferred
2-3 years experience managing RNs, distributed workforce preferred
Basic knowledge of health care contracts, benefit eligibility requirements, hospital structure and payment systems preferred
Applicable knowledge of Milliman and Interqual Criteria required
Current, unrestricted NJ or CA State RN license required
BSN preferred

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.