California Licensed Senior Clinical Manager

Job Summary

Leading second-level clinical monitoring efforts, the remote California Licensed Senior Clinical Manager will oversee compliance across Utilization Management, Claims, and Appeals & Grievances, ensuring high-quality decision-making and operational alignment with regulatory standards.

Key responsibilities

• Direct and perform second-level clinical reviews to evaluate compliance and decision-making accuracy in Utilization Management and Clinical Appeals
• Lead second-level monitoring programs across ODAG functions, ensuring processing accuracy and regulatory alignment
• Analyze monitoring findings to identify root causes and oversee actionable remediation plans for clinical improvement

Required qualifications

• Active, unencumbered Registered Nurse (RN) license
• Minimum of 3+ years of experience in internal monitoring and compliance auditing within a Medicare Advantage health plan
• Demonstrated experience with CMS Program Audits and clinical decision-making protocols
• Proven capability to lead and develop teams in complex or regulated operations
• Strong analytical skills to evaluate clinical process gaps and implement solutions