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Medical Director, Utilization Management

RemoteRemoteFull TimeDirectorPosted 10 days agoVisa sponsorship available

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Required skills

  • MD or DO degree
  • Internal Medicine
  • Family Medicine
  • Emergency Medicine
  • clinical experience
  • Utilization Management reviewer
  • Medicare Advantage experience
  • patient-centered care
  • Clover Assistant

Nice to have

  • outpatient referrals
  • inpatient direct admissions
  • post-acute referral
  • pharmacy
  • peer to peer discussions
  • UM nurses

Role summary

Clover Health is seeking a Medical Director, Utilization Management to evaluate the medical appropriateness of outpatient referrals and inpatient admissions. This role involves utilizing Medicare Coverage Determinations and Milliman Care Criteria to ensure medical necessity. The Medical Director will support UM processes, quality improvement initiatives, and develop clinical guidelines. Key responsibilities include reviewing authorization requests, conducting peer-to-peer discussions, and mentoring UM nurses. Success is measured by efficiency, accuracy, productivity, and contributions to process improvement and patient outcomes. The ideal candidate holds an MD or DO degree, is Board Certified, has a valid medical license, at least five years of clinical experience, and one year of utilization management experience, preferably with Medicare Advantage.

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.

As a Medical Director, Utilization Management, you will:

  • 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.

    • Success in this role looks like:

  • How is success measured in the first 90 days?
  • Successfully completes all required new hire training modules and certifications
  • Demonstrates a foundational understanding of Clover Health's medical policies, guidelines, and utilization management processes
  • Begins to independently review cases with increasing efficiency and accuracy, requiring minimal oversight
  • Establishes positive working relationships with team members and key stakeholders
  • How is success measured in the first 6 months?
  • Consistently meets or exceeds productivity targets for case reviews and determinations.
  • Maintains a high level of accuracy in medical necessity determinations and documentation.
  • Actively participates in team meetings and contributes to process improvement discussions.
  • Demonstrates a comprehensive understanding of complex medical cases and escalates issues appropriately.
  • Provides clear and concise rationales for medical decisions, adhering to regulatory and compliance standards.
  • How will success be measured in the future?
  • Sustained high performance in productivity, accuracy, and adherence to medical policies and guidelines.
  • Proactive identification of opportunities to improve utilization management processes and patient outcomes.
  • Mentorship and support of junior medical directors or clinical staff.
  • Contribution to the development and refinement of medical policies and clinical programs.
  • Ongoing professional development and maintenance of medical licensure and board certifications.
  • Positive feedback from internal and external stakeholders regarding clinical judgment and collaboration.

    • You should get in touch if:

  • 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.

    • Benefits Overview:

  • 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.

    • Additional Perks:

  • 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
  • And much more!

    • About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

    We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

    From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

    #LI-REMOTE / #LI-ONSITE / #LI-HYBRID

    Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

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