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

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

📋 Description

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

• Assess authorization requests for Home Health, acute inpatient, post-acute, outpatient, and pharmacy services to determine medical necessity.

• Act as the lead physician reviewer for intricate Home Health authorization requests that necessitate Medical Director input.

• Analyze episodic and per-visit Home Health authorization requests in accordance with CMS regulations, the Medicare Benefit Policy Manual, NCD/LCDs, and Clover clinical guidelines.

• Review acute inpatient, post-acute, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests while adhering to designated turnaround times.

• Utilize evidence-based medical necessity criteria to foster appropriate utilization across various service lines.

• Serve as the physician point of escalation for challenging Home Health determinations.

• Conduct peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other healthcare providers.

• Collaborate with the Home Health RN Lead to ensure uniform application of coverage criteria.

• Mentor and provide education to Utilization Management nurses regarding complex Home Health cases.

• Participate in reviewer calibration sessions, quality improvement initiatives, and continuous education.

• Aid in the development of clinical guidelines, utilization management policies, and criteria for Home Health reviews.

• Work alongside Home Health agency partners to promote evidence-based practices and enhance documentation quality.

• Contribute to quality improvement efforts for Clover members.

• Achieve proficiency in UM workflows and independently fulfill quality, productivity, and turnaround expectations.

• Offer clinical leadership to enhance utilization management performance and support positive outcomes for members.

⛳️ Requirements

• MD or DO degree.

• Board certification in a relevant specialty.

• Unrestricted medical license in the U.S.

• A minimum of 5 years of clinical experience, including Utilization Management and Medicare Advantage experience.

• Proficiency in reviewing Home Health medical necessity guided by CMS regulations and Medicare coverage criteria.

• Experience in evaluating acute, post-acute, outpatient, and/or pharmacy services.

• Capability to collaborate across interdisciplinary teams.

• Strong communication and peer-to-peer discussion abilities.

• Skills in relationship-building and a commitment to enhancing 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 that supports collaboration and flexibility.

• Learning programs.

• Mentorship.

• Funding for professional development.

• Regular performance feedback and reviews.

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

• Reimbursement for office setup expenses.

• Monthly stipend for cell phone and internet.

• Remote-first culture, facilitating collaboration with global teams.

• Paid parental leave for all new parents.