Lead Medical Director, Utilization Management

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $320k - $340k / year

⏰ Full Time

🟠 Senior

👨‍⚕️ Medical Director

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🏥 Healthcare

🛡️ Insurance

🤖 Artificial Intelligence

Healthcare • Insurance • Artificial Intelligence

Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.

📋 Description

• Evaluate all outpatient referrals and inpatient direct admissions for medical appropriateness • Complete assigned prior authorization, concurrent, retrospective, and other utilization management cases within established turnaround expectations • Ensure clinical decisions align with applicable medical necessity criteria and support clinical integrity of UM reviews • Manage a team of Utilization Management Medical Directors • Review complex or escalated cases and obtain specialty consultation when needed • Develop, review, and maintain clinical policies, pharmacy policies, medical necessity criteria, and UM procedures • Monitor emerging evidence and recommend policy updates • Chair the Utilization Management Committee, including agendas, policy recommendations, utilization trends, decisions, and follow-through • Serve on the Credentialing Committee and provide physician input on credentialing matters, provider qualifications, and clinical concerns • Contribute to the Quality Committee by identifying trends and recommending improvements • Participate in peer-to-peer discussions, appeals, and provider education • Use audits, case reviews, appeals, complaints, and UM performance data to improve policies, clinical practice, and workflows • Partner with care management, quality, compliance, network, pharmacy, and operations teams • Support regulatory and accreditation readiness through clinical documentation, committee records, and corrective actions • Advise organizational leaders on UM strategy, clinical risks, and member and provider experience • Learn UM policies, workflows, committee processes, and documentation expectations during the first 90 days • Complete reviews consistently, contribute to committee work, and identify case or policy trends within the first 6 months • Support clear policies, consistent clinical decisions, committee follow-through, and measurable improvements in quality, access, or outcomes over time

🎯 Requirements

• MD or DO degree and an 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 • Understanding of evidence-based guidelines, coverage policy, quality improvement, and applicable regulatory and accreditation requirements • Strong clinical judgment, clear communication, sound conflict resolution, and ability to contribute effectively in committees

🏖️ 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 • Mental health resources • Generous flexible time-off policy • Remote-first culture supporting collaboration and flexibility • Learning programs • Mentorship • Professional development funding • Regular performance feedback and reviews • 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

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume