[Hiring] Medical Director, Utilization Management @Clover Health

Role Description

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, and 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 requests 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:

• 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.
• 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.
• 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.

Qualifications

• 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

• Financial Well-Being: Competitive base salary and equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and vision coverage.
• Mental Well-Being: Initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.
• Professional Development: 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!