Medical Director, Payment Integrity – Utilization Management

🕒 January 28

🇺🇸 United States – Remote

💵 $270k - $330k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Clover Health (Nasdaq: CLOV) is a physician enablement company focused on seniors who have historically lacked access to affordable, high-quality healthcareWe aim to provide great care, in a sustainable way, by having a business model built around improving medical outcomes while lowering avoidable costs. We do this while taking a holistic approach to understanding the health needs and social risk factors of those under our care. This strategy is underpinned by our proprietary software platform, the Clover Assistant, which is designed to aggregate patient data from across the health ecosystem to support clinical decision-making by presenting physicians and other providers with real-time, personalized recommendations at the point of care.Making care more accessible is at the heart of our business, and we believe patients should have the freedom to choose their doctors. We offer affordable Medicare Advantage plans with extensive benefits, provide primary care physicians with the Clover Assistant, and also make comprehensive home-based care available via the Clover Home Care program.With our corporate headquarters in Nashville, Clover’s workforce is distributed around the U.S. and also includes a team of world-class technologists based in Hong Kong. We manage care for Medicare Advantage members in Alabama, Arizona, Georgia, Mississippi, New Jersey, Pennsylvania, South Carolina, Tennessee, and Texas.We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road.If you’re a passionate person and interested in changing healthcare for the better, then Clover Health may just be the place for you.

📋 Description

• Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines. • Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided. • Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines. • Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives. • Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends. • Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization. • Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making. • Please note: This role is focused on clinical case review and does not require after-hour calls, holidays, or weekends.

🎯 Requirements

• You are an MD or DO with a valid, unrestricted license to practice medicine in a US State. • You are Board Certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine. • You have at least 5 years of clinical experience, including inpatient experience. • You have strong experience in Payment Integrity and Utilization Management/Review and a solid understanding of Medicare Advantage. • You have experience or expertise with peer review committees. • You are extremely detail-oriented and meticulous, and you genuinely enjoy digging into medical records to find the "needle in the haystack". • You possess discerning clinical judgment and an investigative, problem-solving mindset. • You thrive in collaborative, cross-functional settings and have strong proficiency with technology.

🏖️ Benefits

• 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. • 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!