Cloverhealth
Lead Medical Director, Utilization Management
Remote - USA. Posted 9 days ago
The role
The Lead Medical Director, Utilization Management will evaluate outpatient referrals and inpatient direct admissions for medical appropriateness. This role involves managing a team of Utilization Management Medical Directors and developing clinical policies.
What you will do
- Complete assigned prior authorization, concurrent, retrospective, and other UM cases
- Ensure clinical decisions are consistent with medical necessity criteria
- Manage a team of Utilization Management Medical Directors
- Review complex or escalated cases and obtain specialty consultation
- Develop, review, and maintain clinical and pharmacy policies
- Chair the Utilization Management Committee
- Serve on the Credentialing Committee
- Contribute to the Quality Committee
- Participate in peer-to-peer discussions, appeals, and provider education
- Advise organizational leaders on UM strategy and clinical risks
Required qualifications
- MD or DO degree
- Active, unrestricted medical license
- Board certified in a relevant clinical specialty
- At least 5 years of clinical practice experience in utilization management or medical necessity review
- At least 5 years of leadership experience directly managing a clinical team
- Understand evidence-based guidelines, coverage policy, quality improvement, and applicable regulatory and accreditation requirements
- Strong clinical judgment, clear communication, and sound conflict resolution
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
- Flexible time-off policy
- Learning programs, mentorship, and professional development funding
- Employee Stock Purchase Plan (ESPP)
Before you apply
- Will consider qualified applicants with arrest and conviction records pursuant to the San Francisco Fair Chance Ordinance
- E-Verify company
About the company
Clover Health is reinventing health insurance by combining data with human empathy. They use custom software and analytics to provide personalized care to seniors.