California Licensed Senior Clinical Manager

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