Senior Clinical/Operations Internal Monitoring Manager

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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