Clover Health - Registered Nurse (RN) Medicare Quality Assurance Reviewer

• 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. • 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.