Manager of Utilization Management at Clover Health
Jersey City, NJ, US
Clover is reinventing health insurance by working to keep people healthier.

Our clinical team is a group of caring and passionate professionals dedicated to improving the lives of our members by conducting in-home visits. Our team that helps make this possible include; Medical Directors, Nurse Practitioners, Medical Assistants, Social Workers, and Utilization Management Nurses.

You will work directly with the Medical Director to coordinate and manage the clinical review team. In addition to staff management, you'll be 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. You'll be 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, you will also facilitate 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.

As a Manager of Utilization Management, you will:

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.


Be responsible for 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 report on utilization, health outcomes, care coordination and expenses with a 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.

You will love this job if:

You are a people person. You enjoy interacting with different types of people every single day.
You want to make a difference. You feel fulfilled when you can help members have healthier lives.
You are detail-oriented. You have great follow-up skills and can prioritize and self-managing your work.
You like to learn. Healthcare and technology are complicated. You are passionate about understanding how these two things come together.

You should get in touch if:

You have a current, unrestricted RN license.
You have applicable knowledge of Milliman and Interqual Criteria.
You have 2+ years experience managing a team of RNs, and preferably some experience with a remote workforce.
You have 3+ years experience as a case manager, concurrent review nurse, utilization review nurse.
You are very comfortable with technology - in particular, learning new software systems and navigating Mac OS X.
You have basic knowledge of health care contracts, benefit eligibility requirements, hospital structure and payment systems.

We are an E-Verify company.