Senior Manager, Quality Improvement

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