Senior Clinical/Operations Internal Monitoring Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Lead and manage second-level auditor oversight in Utilization Management, Claims, and Appeals & Grievances.

• Perform clinical assessments for Utilization Management and clinical appeals.

• Assess the accuracy of auditor decision-making, compliance with clinical hierarchy, medical policies, and adherence to evidence-based guidelines.

• Direct second-level monitoring initiatives and evaluate operational controls, including SOX Claims QA Control testing.

• Mentor, coach, and develop the Internal Monitoring team.

• Establish priorities and performance expectations, distribute tasks, and oversee quality and outcomes.

• Analyze monitoring results and data trends to pinpoint root causes and process weaknesses.

• Supervise corrective actions and remediation strategies.

• Evaluate internal controls, clinical decision-making protocols, standard operating procedures (SOPs), and regulatory guidelines.

• Compile and present monthly reports on quality performance and monitoring activities.

• Collaborate with operational leaders, Compliance, processing teams, business partners, and BPaaS vendors.

• Validate remediation efforts through targeted post-remediation evaluations.

• Support quality initiatives and initiate focused quarterly audits based on emerging clinical risks.

• Create training materials and refresher sessions to enhance decision-making capabilities.

• Develop and maintain monitoring instruments, playbooks, SOPs, audit workbooks, and documentation for audit readiness.

• Assist in CMS Program Audit preparation, conduct mock audits, validate audit data universes, and support regulatory compliance efforts.

• Utilize AI-driven audit tools, machine learning analytics, and automated reporting workflows.

• Contribute to establishing the 6–12 month Internal Monitoring strategy, priorities, capacity, and operational approach.

⛳️ Requirements

• A valid, unencumbered Registered Nurse (RN) license is mandatory.

• At least 3+ years of direct experience in internal monitoring, clinical quality oversight, or compliance auditing within a Medicare Advantage health plan.

• Proven experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and operational guidelines for Medicare Advantage.

• Familiarity with the MCG clinical decision-making tool is highly preferred.

• Demonstrated ability to influence cross-functional clinical teams and work collaboratively with BPaaS vendors.

• Experience in leading and developing teams, including setting priorities, managing performance, coaching employees, allocating resources, and enhancing team capabilities across complex or regulated environments.

• Outstanding project management, prioritization, and organizational skills.

• Strong analytical and conceptual skills for risk anticipation, evaluating clinical process gaps, conducting root-cause analysis, and implementing forward-thinking solutions.

• High attention to detail with excellent documentation, verbal/written communication, and systems proficiency.

• Ability to achieve results independently while promoting a positive, team-oriented atmosphere.

• Capacity to stay updated on processes, regulatory guidance, and company policies.

• Ability to perform under pressure to meet stringent regulatory and audit timelines, with adaptability during peak operational or audit periods.

🏝️ Benefits

• Competitive base salary.

• Equity opportunities.

• Performance-based bonus program.

• 401(k) matching.

• Regular compensation reviews.

• Comprehensive medical coverage.

• Dental coverage.

• Vision coverage.

• No-Meeting Fridays.

• Monthly company holidays.

• Mental health resources.

• Generous flexible time-off policy.

• Remote-first culture.

• Learning programs.

• Mentorship.

• Professional development funding.

• Regular performance feedback and reviews.

• Employee Stock Purchase Plan (ESPP) with discounted equity opportunities.

• Reimbursement for office setup costs.

• Monthly stipend for cell phone and internet expenses.

• Collaboration with global teams.

• Paid parental leave for all new parents.