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.…