Medical Director, Utilization Management

The Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health's medical policies reviews to determine medical necessity or if an alternate treatment plan is required for our members.

Responsibilities

Participate and support the Clover Health Utilization Management processes; Support Quality improvement initiatives for Clover members; Review Utilization Management authorization requests for medical necessity; Evaluate authorizations for outpatient referral, inpatient direct admissions, post-acute referral, 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 to strengthen Utilization Management effectiveness; Support the ongoing development of Clover Health's clinical guidelines and policies; Maintain credentials as required for employment with Clover Health

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 superior, personalized, patient-centered care; Genuine interest in leveraging technology to help people and a positive attitude toward tackling industry challenges

Benefits

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; Learning programs, mentorship, and professional development funding; Regular performance feedback and reviews; Employee Stock Purchase Plan (ESPP); Reimbursement for office setup expenses; Monthly cell phone and internet stipend; Paid parental leave for all new parents