Senior Clinical/Operations Internal Monitoring Manager

About this role

The Senior Manager of Internal Monitoring plays a pivotal role in leading and overseeing second-level auditor monitoring across all ODAG functions—including Utilization Management (UM), Claims, and Appeals & Grievances—to ensure operational compliance and alignment with regulatory standards and Clover policies.
Specifically, this role provides direct clinical monitoring leadership by conducting clinical evaluations for UM and clinical appeals to guarantee high-quality, sound clinical decision-making. In addition to guiding monitoring workflows and evaluating operating controls, the Senior Manager conducts risk-based operational audits, assesses alignment with clinical hierarchy, and drives process optimization through Artificial Intelligence (AI) integration. The Senior Manager also analyzes quality trends and root causes, delivers executive performance reporting, and collaborates cross-functionally with internal business leaders and BPaaS partners to resolve operational risks and execute effective remediation strategies. This role is also accountable for leading the Internal Monitoring function across clinical and non-clinical second-level monitoring, including helping to set the 6-12 month strategy, priorities, capacity, and operating approach. The Senior Manager leads and develops the Internal Monitoring team and ensures people, processes, and monitoring capabilities are aligned to evolving regulatory and business risks.
As a Senior Cinical/Operations Internal Monitoring Manager, you will:

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Clinical Monitoring (UM & Clinical Appeals): Direct and perform second-level clinical reviews across Utilization Management (UM) and Clinical Appeals to evaluate auditor decision-making accuracy, compliance with clinical hierarchy, and adherence to medical policies and evidence-based guidelines.

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ODAG Second-Level Monitoring Management: Lead second-level monitoring programs encompassing all ODAG operational areas (UM, Claims, and Appeals & Grievances) to verify processing accuracy, maintain regulatory alignment, and evaluate key operating controls, including Sarbanes-Oxley (SOX) Claims QA Control testing.

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Lead and Develop the Internal Monitoring Team: Lead, coach, and develop team members responsible for clinical and non-clinical monitoring across ODAG functions. Set clear priorities and performance expectations, allocate work based on regulatory risk and capacity, hold team members accountable for quality and outcomes, and build the capabilities needed to deliver sustained monitoring effectiveness.

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Audit Analysis & Corrective Action: Analyze monitoring findings and data trends to identify root causes, uncover clinical improvement opportunities and process vulnerabilities, and oversee actionable remediation plans.

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Controls & Governance Assessment: Execute deep-dive clinical monitoring reviews to test the adequacy, effectiveness, and strength of internal controls, clinical decision-making protocols, standard operating procedures (SOPs), and regulatory guidance.

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Reporting & Stakeholder Engagement: Prepare and present comprehensive monthly quality performance and monitoring reports to key operational leaders, BPaaS and business partners, and compliance providing clear feedback, customer impact analysis, and actionable recommendations.

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Remediation & Risk Mitigation: Partner with processing teams, business leaders, Compliance, and BPaaS partners to design effective remediation strategies, follow monitoring errors through remediation, and validate results through focused post-remediation reviews.

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Quality Management & Focused Projects: Support quality projects and maintain monitoring tools to expand clinical quality monitoring, initiating focused quarterly audits based on emerging clinical risks.

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Training & Intervention: Identify critical clinical gaps requiring monitoring intervention. Work with business teams to support development of plans, tailored training materials, and refresher sessions to promote improved decision-making performance.

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Documentation: Develop, standardize, and maintain comprehensive ODAG Monitoring tools and Playbooks, standard operating procedures (SOPs), audit workbooks, and audit readiness documentation to safeguard operational consistency and support Compliance Business Continuity.

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CMS Regulatory & Audit Support: Serve as a key contributor to CMS Program Audit preparation, mock audits, ODAG audit data universe validation, and regulatory decision-making protocol compliance initiatives.

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Artificial Intelligence (AI) Integration: Leverage AI-driven audit tools, machine learning analytics, and automated reporting workflows to optimize sampling methodologies, detect emerging compliance risks, and elevate the accuracy and scalability of clinical monitoring operations.

You should get in touch if:

• You have active, unencumbered Registered Nurse (RN) license required.

• You have minimum of 3+ years of direct experience in internal monitoring, clinical quality oversight, compliance auditing within a Medicare Advantage health plan.

• You have a demonstrated experience with CMS Program Audits, ODAG audit data universes, clinical decision-making protocols, and Medicare Advantage operational guidelines. Knowledge of the MCG clinical decision-making tool is highly desirable.

• You have a proven capability to influence cross-functional clinical teams and collaborate effectively with BPaaS vendors.

• You have a demonstrated experience leading and developing teams, including setting priorities, managing performance, coaching employees, allocating capacity, and building team capability across complex or regulated operations.

• You have exceptional project management, prioritization, and organizational skills with the ability to navigate complex clinical priorities in a fast-paced environment.

• You have strong analytical and conceptual capabilities to anticipate risks, evaluate clinical process gaps, perform root-cause analysis, and implement…