At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most.
This role requires an experienced Registered Nurse (RN) with strong knowledge of regulatory requirements, QI methodology, and Medicare Advantage program compliance. You will partner cross-functionally with internal and external stakeholders to strengthen Clover’s QI Program, ensuring compliance, operational excellence, and continuous improvement in care delivery.
As a Senior Manager, Quality Improvement, you will:
- Oversee Regulatory QI Program Elements
- Lead development and maintenance of the Annual Quality Improvement Program Description and Annual QI Work Plan in compliance with CMS MMCM Chapters 4 and 5.
- Ensure timely completion of annual QI Program Evaluation, incorporating performance results and regulatory updates.
- Manage QI Committee activities, ensuring documentation, reporting, and escalation of findings to governance bodies.
- Regulatory Compliance & Audit Readiness
- Ensure CMS, NCQA, and state QI requirements are met and documented.
- Maintain audit readiness for CMS Program Audits and state/federal reviews.
- Partner with Legal and Compliance teams to interpret new regulations and implement operational changes.
- Quality of Care Oversight
- Oversee Quality of Care (QOC) investigations, including case review, root cause analysis, and corrective action planning.
- Collaborate with Medical Directors and clinical teams on QOC determinations and improvement strategies.
- Performance Monitoring & Improvement
- Support Star Ratings strategy by evaluating performance data and identifying barriers to improvement.
- Present QI outcomes, trends, and opportunities to senior leadership and regulatory committees.
- Implement cross-functional improvement initiatives using rapid-cycle QI methodology.
- Leadership & Collaboration
- Supervise a team of QI professionals, providing coaching and professional development.
- Lead cross-departmental working groups to drive execution of the QI Work Plan.
- Foster a culture of quality, compliance, and continuous improvement across the organization.
Success in this role looks like:
- How is success measured in the first 90 days?
- Understand Clover Health’s QI program, CMS MMCM requirements, and regulatory obligations.
- Assess current QI processes, identify gaps, and begin building relationships with key stakeholders.
- Develop a preliminary plan to address immediate compliance or operational issues.
- How is success measured in the first 6 months?
- Update or implement QI program elements to ensure regulatory compliance.
- Launch at least one improvement initiative addressing a high-priority quality gap.
- Establish performance monitoring, present data-driven insights, and strengthen QI Committee operations.
- Coach and develop QI team members, clarifying roles and expectations.
- How will success be measured in the future?
- Maintain full regulatory compliance and audit readiness.
- Improve care quality outcomes and support Star Ratings performance.
- Embed a culture of continuous improvement across the organization.
- Ensure an engaged, high-performing QI team contributing to organizational goals.
You should get in touch if:
- Active, unrestricted RN license (required).
- Bachelor’s degree in Nursing or a related field (Master’s preferred).
- Minimum 3 years of experience in Medicare Advantage or similar managed care setting.
- Deep knowledge of CMS MMCM Chapter 4 (Benefits & Beneficiary Protections) and Chapter 5 (Quality Improvement Program) requirements.
- Experience in regulatory compliance, QI program oversight, and audit readiness.
- At least 3 years of leadership experience, including direct team management.
- Strong skills in data analysis, performance monitoring, and process improvement.
- Proficiency with Microsoft Office and Google Suite.
- Excellent written and verbal communication skills; ability to present to executive leadership and committees.
Benefits Overview:
- Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
- Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
- Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
- Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
Additional Perks:
- Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
- Reimbursement for office setup expenses
- Monthly cell phone & internet stipend
- Remote-first culture, enabling collaboration with global teams
- Paid parental leave for all new parents
- And much more!
About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.
We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.
From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.
A reasonable estimate of the base salary range for this role is $140,000 to $171,000. Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.
#LI-Remote
