Medical Director, Utilization Management

The role

The Medical Director, Utilization Management will evaluate outpatient referrals and inpatient direct admissions for medical appropriateness. The physician will use Medicare Coverage Determinations, Milliman Care Criteria, and medical policies to determine medical necessity.

What you will do

• 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.

Required qualifications

• 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.

Benefits

• Competitive base salary
• Equity opportunities
• Performance-based bonus program
• 401k matching
• Regular compensation reviews
• Comprehensive medical, dental, and vision coverage
• No-Meeting Fridays
• Monthly company holidays
• Access to mental health resources
• Generous flexible time-off policy
• Learning programs
• Mentorship

Before you apply

• We will consider for employment qualified applicants with arrest and conviction records.
• We are an E-Verify company.

About the company

Clover Health is reinventing health insurance by combining the power of data with human empathy. They use custom software and analytics to empower clinical staff to provide personalized care.