Medical Director, Utilization Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Engage in and assist with Clover Health's Utilization Management processes.

• Aid in quality improvement initiatives aimed at enhancing the experiences of Clover members.

• Assess Utilization Management authorization requests to ensure medical necessity.

• Review authorizations for outpatient referrals, direct admissions to hospitals, post-acute referrals, and pharmacy requests within set timelines.

• Conduct peer-to-peer discussions and foster collaborative relationships with healthcare providers in the community and hospitals.

• Offer mentoring and coaching to Utilization Management nurses.

• Contribute to the continuous development of Clover Health’s clinical guidelines and policies.

• Maintain necessary credentials as a condition of employment.

• Complete mandatory training modules and certifications for new hires.

• Independently evaluate cases while increasing efficiency and accuracy.

• Achieve or surpass productivity targets related to case reviews and determinations.

• Ensure precision in medical-necessity determinations and documentation.

• Engage in discussions aimed at process improvement.

• Appropriately escalate complex issues.

• Provide clear justifications for medical decisions in adherence to regulatory standards.

• Identify chances to enhance utilization management processes and outcomes for patients.

• Mentor junior medical directors or clinical staff members.

• Contribute to the formulation of medical policies and clinical program development.

• Keep medical licensure and board certifications up to date.

⛳️ Requirements

• MD or DO degree required.

• Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty.

• Valid and unrestricted medical license to practice in a U.S. state.

• At least five years of clinical experience required.

• Minimum of one year of experience as a Utilization Management reviewer.

• Experience in Medicare Advantage is a plus.

• Commitment to enhancing members’ quality of life through personalized, patient-centered care.

• Genuine enthusiasm for utilizing technology in healthcare.

• Positive disposition toward addressing significant challenges within the industry.

🏝️ Benefits

• Competitive base salary.

• Equity opportunities available.

• Performance-driven bonus program.

• 401(k) matching offered.

• Regular compensation evaluations.

• Comprehensive coverage for medical, dental, and vision needs.

• No-Meeting Fridays to enhance productivity.

• Monthly company holidays.

• Resources for mental health support.

• Generous flexible time-off policy.

• Remote-first culture that promotes collaboration and flexibility.

• Opportunities for continuous learning.

• Mentorship programs available.

• Funding for professional development.

• Regular performance feedback and evaluations.

• Employee Stock Purchase Plan (ESPP) offering discounted equity options.

• Reimbursement for home office setup expenses.

• Monthly stipend for cell phone and internet expenses.

• Collaboration with global teams.

• Paid parental leave for all new parents.