Medical Director, Utilization Management

September 11

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Clover Health

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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.

501 - 1000 employees

📋 Description

• Evaluate all outpatient referrals and inpatient direct admissions for medical appropriateness • Utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, and Clover Health medical policies to determine medical necessity or recommend alternate treatment plans • Participate in and support Clover Health Utilization Management processes • Support quality improvement initiatives for Clover members • Review Utilization Management authorization requests for medical necessity within established timelines • Evaluate authorizations for outpatient referral, inpatient direct admissions, post-acute referral, and pharmacy • 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 required medical credentials and board certifications

🎯 Requirements

• 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 • Dedicated to improving members’ quality of life by providing superior, personalized, patient-centered care • Genuine interest in leveraging technology to help people and a positive attitude toward industry challenges • Maintain credentials as required for employment with Clover Health

🏖️ Benefits

• Our commitment to attracting and retaining top talent begins with a competitive base salary and 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 • Remote-first culture, enabling collaboration with global teams • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Paid parental leave for all new parents