Lead Medical Director, Utilization Management

Clover Health

10h•$320,000 - $340,000•Remote

About The Position

At Clover Health, the Utilization Management team supports access to appropriate care through timely, evidence-based medical necessity decisions and clear clinical policies. The Lead Medical Director, Utilization Management, evaluates outpatient referrals and inpatient direct admissions for medical appropriateness, using Local and National Medicare Coverage Determinations, Milliman Care Criteria, and Clover Health medical policy reviews to determine medical necessity or whether an alternate treatment plan is required. The role leads a team of Utilization Management Medical Directors and completes assigned prior authorization, concurrent, retrospective, and other utilization management reviews. It supports consistent, clinically sound decisions; develops and maintains clinical policies and procedures; leads committee work; and partners with teams across the organization to improve care quality, access, outcomes, and the member and provider experience. In the first 90 days, the Lead is expected to learn UM policies, workflows, committee processes, and documentation expectations and begin completing reviews. Within six months, the Lead is expected to complete reviews consistently and on time, contribute to committee work, and identify relevant case or policy trends. Over time, the role supports current policies, consistent decisions, effective committee follow-through, and measurable improvements in quality, access, or outcomes. Clover Health describes itself as a remote-first organization focused on improving healthcare for seniors through data, technology, and personalized care. The company offers a competitive base salary and equity opportunities. The estimated base salary range for this role is $320,000–$340,000 USD; final pay depends on factors including internal equity, market data, education, work experience, and certifications.

Requirements

MD or DO degree.
Active, unrestricted medical license.
Board certification in a relevant clinical specialty.
At least 5 years of clinical practice experience in utilization management or medical necessity review.
At least 5 years of leadership experience directly managing a clinical team.
Understanding of evidence-based guidelines, coverage policy, quality improvement, and applicable regulatory and accreditation requirements.
Strong clinical judgment, clear communication, sound conflict resolution, and ability to contribute effectively in committees.

Responsibilities

Complete assigned prior authorization, concurrent, retrospective, and other UM cases with sound clinical judgment and within established turnaround expectations.
Ensure clinical decisions are consistent with applicable medical necessity criteria and support the clinical integrity of UM reviews.
Manage a team of Utilization Management Medical Directors.
Review complex or escalated cases and obtain appropriate specialty consultation when needed.
Develop, review, and maintain clinical policies, pharmacy policies, medical necessity criteria, and UM procedures with clinical experts and operational teams; monitor emerging evidence and recommend updates.
Chair the Utilization Management Committee by setting agendas, presenting policy recommendations and utilization trends, documenting decisions, and following through on committee actions.
Serve on the Credentialing Committee and provide physician input on credentialing matters, provider qualifications, and clinical concerns.
Contribute to the Quality Committee by identifying trends in care quality, access, and outcomes and recommending opportunities for improvement.
Participate in peer-to-peer discussions, appeals, and provider education as needed, communicating clinical decisions clearly and respectfully.
Use audit findings, case reviews, appeals, complaints, and UM performance data to identify variation and improve policies, clinical practice, and workflows.
Partner with care management, quality, compliance, network, pharmacy, and operations teams on issues that cross clinical programs.
Support regulatory and accreditation readiness through appropriate clinical documentation, committee records, and corrective actions within the role’s scope.
Advise organizational leaders on UM strategy, clinical risks, and opportunities to improve the member and provider experience.
Learn UM policies, workflows, committee processes, and documentation expectations, and begin completing assigned reviews during the first 90 days.
Within the first six months, complete reviews consistently and on time, contribute to committee work, and identify relevant case or policy trends.
Support clear and current policies, consistent clinical decisions, effective committee follow-through, and measurable improvements in quality, access, or outcomes over time.