Senior Clinical/Operations Internal Monitoring Manager
Core
Lead second-level clinical and operational monitoring for Utilization Management, Claims, and Appeals to ensure compliance with regulatory standards and clinical policies.
Role type
Senior Clinical/Operations Internal Monitoring Manager
Builds
Operational compliance and clinical decision-making quality within Medicare Advantage health plans
Domain
Healthcare / Medicare Advantage / Clinical Auditing
Required skills
Registered Nurse (RN) license, internal monitoring leadership, clinical quality oversight, CMS Program Audit experience, team development, root-cause analysis, AI tool integration, regulatory compliance, process optimization
Preferred skills
MCG clinical decision-making tool knowledge, BPaaS vendor collaboration, project management, analytical capabilities
Technologies
AI-driven audit tools, machine learning analytics, automated reporting workflows
Responsibilities
Conduct second-level clinical reviews for UM and Clinical Appeals, lead monitoring programs across ODAG functions, develop and coach the internal monitoring team, analyze monitoring findings to drive remediation, execute controls and governance assessments, prepare executive performance reports, support CMS Program Audits, integrate AI tools into monitoring operations
Seniority
Senior, hands-on IC with team leadership
