Medical Director, Utilization Management

Clover Health

115d • $207,000 - $253,000

About The Position

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. The Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health’s medical policies reviews to determine medical necessity or if an alternate treatment plan is required for our members.

Requirements

• You have an MD or DO degree.
• You have Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty.
• You have a valid, unrestricted license to practice medicine in a U.S. state.
• You have a minimum of five years of clinical experience.
• You have at least one year of experience as a Utilization Management reviewer.
• You have Medicare Advantage experience.
• You are dedicated to improving members’ quality of life by providing superior, personalized, patient-centered care.
• You have a genuine interest in leveraging technology to help people and maintain a positive attitude toward tackling important industry challenges.

Responsibilities

• Participate and support the Clover Health Utilization Management processes.
• Support Quality improvement initiatives for Clover members.
• Review Utilization Management authorization request for medical necessity.
• Evaluate authorizations for outpatient referral, inpatient direct admissions, post-acute referral, 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’s clinical guidelines and policies.
• Maintain credentials as required for employment with Clover Health.

Benefits

• Competitive base salary and equity opportunities.
• Performance-based bonus program.
• 401k matching.
• Comprehensive medical, dental, and vision coverage.
• Mental health resources and flexible time-off policy.
• Remote-first culture.
• Learning programs and professional development funding.
• Employee Stock Purchase Plan (ESPP).
• Reimbursement for office setup expenses.
• Monthly cell phone & internet stipend.
• Paid parental leave for all new parents.

What This Job Offers

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