Medical Director, Utilization Management

Clover Health

8d•Remote

About The Position

The Medical Director, Utilization Management evaluates outpatient referrals and inpatient direct admissions for medical appropriateness. The physician uses 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 for members. The role supports Clover Health’s Utilization Management processes and quality improvement initiatives. It reviews authorization requests for medical necessity and evaluates outpatient referrals, inpatient direct admissions, post-acute referrals, and pharmacy authorizations within established timelines. The Medical Director conducts peer-to-peer discussions, builds collaborative relationships with community and hospital providers, mentors and coaches UM nurses, supports the ongoing development of clinical guidelines and policies, and maintains credentials required for employment. Success involves completing required training and certifications, developing a strong understanding of medical policies and UM processes, and progressively reviewing cases independently with accuracy and efficiency. The role is expected to meet productivity and accuracy targets, contribute to process improvement, handle complex cases appropriately, provide clear rationales that comply with regulatory standards, and help refine policies and clinical programs. Clover describes its culture as remote-first and offers collaboration and flexibility from any location.

Requirements

MD or DO degree.
Board certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty.
Valid, unrestricted license to practice medicine in a U.S. state.
Minimum of five years of clinical experience.
At least one year of experience as a Utilization Management reviewer.
Medicare Advantage experience.
Dedication to improving members’ quality of life through superior, personalized, patient-centered care.
Genuine interest in leveraging technology to help people and a positive attitude toward tackling industry challenges.
Maintain medical licensure and board certifications.

Responsibilities

Participate in and support Clover Health Utilization Management processes.
Support quality improvement initiatives for Clover members.
Review Utilization Management authorization requests for medical necessity.
Evaluate authorizations for outpatient referrals, inpatient direct admissions, post-acute referrals, and pharmacy within established timelines.
Perform peer-to-peer discussions and build collaborative relationships with community and hospital providers.
Provide mentoring and coaching to UM nurses to strengthen Utilization Management effectiveness.
Support the ongoing development of Clover Health clinical guidelines and policies.
Maintain credentials required for employment with Clover Health.
Meet productivity targets and maintain accuracy in case reviews, determinations, and documentation.
Contribute to process improvement discussions and identify opportunities to improve Utilization Management processes and patient outcomes.
Provide clear and concise rationales for medical decisions in accordance with regulatory and compliance standards.