Medical Director, Utilization Management – Home Health, Acute & Post-Acute

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🔥 8 minutes ago

🇺🇸 United States – Remote

💵 $242.3k - $315k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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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

• Participate in and support Clover Health Utilization Management processes. • Review authorization requests for Home Health, acute inpatient, post-acute, outpatient, and pharmacy services for medical necessity. • Serve as the primary physician reviewer for complex Home Health authorization requests requiring Medical Director determination. • Review episodic and per-visit Home Health authorization requests using CMS regulations, the Medicare Benefit Policy Manual, NCD/LCDs, and Clover clinical guidelines. • Evaluate acute inpatient, post-acute, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests within established turnaround times. • Apply evidence-based medical necessity criteria and promote appropriate utilization across service lines. • Serve as the physician escalation point for complex Home Health determinations. • Perform peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other providers. • Partner with the Home Health RN Lead to ensure consistent application of coverage criteria. • Mentor and educate Utilization Management nurses on complex Home Health cases. • Participate in reviewer calibration sessions, quality initiatives, and ongoing education. • Support development of clinical guidelines, utilization management policies, and Home Health review criteria. • Collaborate with Home Health agency partners to promote evidence-based care and improve documentation quality. • Support quality improvement initiatives for Clover members. • Become proficient in UM workflows and independently meet quality, productivity, and turnaround expectations. • Provide clinical leadership, improve utilization management performance, and support positive member outcomes.

🎯 Requirements

• MD or DO degree • Board certification in a relevant specialty • Unrestricted U.S. medical license • 5+ years of clinical experience, including Utilization Management and Medicare Advantage experience • Expertise reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria • Experience reviewing acute, post-acute, outpatient, and/or pharmacy services • Ability to collaborate across interdisciplinary teams • Effective communication and peer-to-peer discussion skills • Relationship-building skills and passion for improving member outcomes through innovation and technology

🏖️ 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 • Remote-first culture, enabling collaboration with global teams • Paid parental leave for all new parents