Medical Director, Utilization Management (Home Health, Acute & Post-Acute)

Clover Health

5d•$242,300 - $315,000•Remote

About The Position

The Utilization Management (UM) team is made up of experienced physicians and clinicians who work together to ensure Clover members receive medically appropriate, evidence-based care while optimizing quality and resource utilization. As the Medical Director, Utilization Management, you will play a critical role in supporting timely utilization decisions across the continuum of care, with a primary focus on Home Health services while also reviewing acute, post-acute, outpatient, and pharmacy authorization requests. In this role, you will serve as the physician leader for Home Health utilization management, reviewing complex authorization requests for episodic and per-visit services to determine medical necessity. Leveraging CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines, and Clover Health clinical policies, you will help ensure consistent, evidence-based decision-making that supports high-quality member care. You'll partner closely with the Home Health RN Lead, Utilization Management nurses, providers, and cross-functional teams to improve clinical outcomes, promote appropriate utilization, and advance Clover's commitment to delivering exceptional Home Health services.

Requirements

MD or DO degree
Board certified in a relevant specialty
Unrestricted U.S. medical license
5+ years of clinical experience
Utilization Management experience
Medicare Advantage experience
Expertise reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria
Experience reviewing acute, post-acute, outpatient, and/or pharmacy services
Enjoy collaborating across interdisciplinary teams to deliver high-quality, evidence-based care
Effective communicator who thrives in peer-to-peer discussions
Values relationship building
Passionate about improving member outcomes through innovation and technology

Nice To Haves

Experience serving as a Medical Director or physician reviewer is preferred.

Responsibilities

Participate in and support Clover Health Utilization Management processes.
Review authorization requests for Home Health, acute inpatient, post-acute, outpatient, and pharmacy services for medical necessity.
Serve as the primary physician reviewer for complex Home Health authorization requests requiring Medical Director determination.
Review both episodic and per-visit Home Health authorization requests using CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines.
Evaluate acute inpatient admissions, post-acute services, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests within established turnaround times.
Apply evidence-based medical necessity criteria while promoting appropriate utilization across all service lines.
Serve as the physician escalation point for complex Home Health medical necessity determinations submitted by the Utilization Management nursing team.
Perform peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other providers to facilitate appropriate care decisions.
Partner with the Home Health RN Lead to ensure consistent interpretation and application of Home Health coverage criteria.
Mentor and educate Utilization Management nurses on complex Home Health cases, including episodic and per-visit review methodologies.
Participate in Home Health reviewer calibration sessions, quality initiatives, and ongoing education to improve consistency and decision quality.
Support the ongoing development of Clover Health clinical guidelines, utilization management policies, and Home Health review criteria.
Collaborate with Home Health agency partners to promote evidence-based care, improve documentation quality, and support optimal member outcomes.
Support quality improvement initiatives for Clover members.