Medical Director, Utilization Management

🔥 29 minutes ago

🇺🇸 United States – Remote

⏰ 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 • Support quality improvement initiatives for Clover members • Review Utilization Management authorization requests for medical necessity • Evaluate authorizations for outpatient referrals, inpatient direct admissions, post-acute referrals, 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 • Support the ongoing development of Clover Health’s clinical guidelines and policies • Maintain credentials as required for employment • Complete required new-hire training modules and certifications • Independently review cases with increasing efficiency and accuracy • Meet or exceed productivity targets for case reviews and determinations • Maintain accuracy in medical-necessity determinations and documentation • Participate in process-improvement discussions • Escalate complex issues appropriately • Provide clear rationales for medical decisions in compliance with regulatory standards • Identify opportunities to improve utilization-management processes and patient outcomes • Mentor junior medical directors or clinical staff • Contribute to medical policy and clinical program development • Maintain medical licensure 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 • Dedication to improving members’ quality of life through personalized, patient-centered care • Genuine interest in leveraging technology • Positive attitude toward tackling important industry challenges

🏖️ Benefits

• Competitive base salary • Equity opportunities • Performance-based bonus program • 401(k) 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 • Collaboration with global teams • Paid parental leave for all new parents

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