Medical Director, Payment Integrity & Utilization Management

Clover Health • Jersey City, NJ

2d • $270,000 - $330,000 • Remote

About The Position

Clover is reinventing health insurance by working to keep people healthier. We are a Medicare Advantage plan working to develop deeper insights to drive better outcomes for our members through our integrated technology platform. We rely on our abilities to integrate standard health plan data with clinical information from provider health information systems. The Medical Management team is at the center of this work, ensuring our members receive high-quality, appropriate care. We are looking for an extremely detail-oriented Medical Director with a strong background in Payment Integrity (PI) and Utilization Management (UM). This is a full-time, hands-on role for someone who thrives "in the weeds" and enjoys the challenge of deep medical record review. You will be responsible for using your discerning clinical judgment to ensure medical necessity, appropriate utilization, and payment accuracy. This position reports to the Chief Medical Officer, Medicare Advantage (CMO). As a Medical Director, Payment Integrity & Utilization Management, you will: Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines. Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided. Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines. Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives. Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends. Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization. Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making. Please note: This role is focused on clinical case review and does not require after-hour calls, holidays, or weekends. Success in this role looks like: By 90 Days : You have onboarded and familiarized yourself with company policies, workflows, and the specific PI/UM review processes. You've begun building rapport with the Medical Management team and key stakeholders. You are participating in case reviews with oversight, demonstrating your meticulous attention to detail and learning the technical tools. By 6 Months : You are autonomously managing a significant volume of complex case reviews, making independent clinical decisions aligned with company guidelines and medical standards. You are identifying opportunities for process improvements in the PI and UM review process and are actively collaborating with the interdisciplinary team. Ongoing : You are recognized as a subject-matter expert in Payment Integrity and medical necessity review, handling the most complex or high-stakes cases with high accuracy. You are playing a key role in shaping review strategies and guidelines and driving continuous improvement in our quality assurance processes.

Requirements

• You are an MD or DO with a valid, unrestricted license to practice medicine in a US State.
• You are Board Certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine.
• You have at least 5 years of clinical experience, including inpatient experience.
• You have strong experience in Payment Integrity and Utilization Management/Review and a solid understanding of Medicare Advantage.
• You have experience or expertise with peer review committees.
• You are extremely detail-oriented and meticulous, and you genuinely enjoy digging into medical records to find the "needle in the haystack".
• You possess discerning clinical judgment and an investigative, problem-solving mindset.
• You thrive in collaborative, cross-functional settings and have strong proficiency with technology.

Responsibilities

• Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines.
• Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided.
• Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines.
• Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives.
• Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends.
• Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization.
• Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making.

Benefits

• 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.
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree
• Number of Employees: 501-1,000 employees