Medical Director, Utilization Management (Home Health, Acute & Post-Acute)

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About the role

The Utilization Management (UM) team is made up of experienced physicians and clinicians who work together to ensure Clover members receive medically appropriate, evidence-based care while optimizing quality and resource utilization. As the Medical Director, Utilization Management, you will play a critical role in supporting timely utilization decisions across the continuum of care, with a primary focus on Home Health services while also reviewing acute, post-acute, outpatient, and pharmacy authorization requests. In this role, you will serve as the physician leader for Home Health utilization management, reviewing complex authorization requests for episodic and per-visit services to determine medical necessity. Leveraging CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines, and Clover Health clinical policies, you will help ensure consistent, evidence-based decision-making that supports high-quality member care. You'll partner closely with the Home Health RN Lead, Utilization Management nurses, providers, and cross-functional teams to improve clinical outcomes, promote appropriate utilization, and advance Clover's commitment to delivering exceptional Home Health services. As a Medical Director, Utilization Management, you will: • 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 both episodic and per-visit Home Health authorization requests using CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines. • Evaluate acute inpatient admissions, post-acute services, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests within established turnaround times. • Apply evidence-based medical necessity criteria while promoting appropriate utilization across all service lines. • Serve as the physician escalation point for complex Home Health medical necessity determinations submitted by the Utilization Management nursing team. • Perform peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other providers to facilitate appropriate care decisions. • Partner with the Home Health RN Lead to ensure consistent interpretation and application of Home Health coverage criteria. • Mentor and educate Utilization Management nurses on complex Home Health cases, including episodic and per-visit review methodologies. • Participate in Home Health reviewer calibration sessions, quality initiatives, and ongoing education to improve consistency and decision quality. • Support the ongoing development of Clover Health clinical guidelines, utilization management policies, and Home Health review criteria. • Collaborate with Home Health agency partners to promote evidence-based care, improve documentation quality, and support optimal member outcomes. • Support quality improvement initiatives for Clover members. Success in this role looks like: Within your first 90 days, you will: • Become fully proficient in Clover's Utilization Management workflows, Home Health review processes, CMS regulations, and Medicare coverage criteria through successful onboarding and training. • Independently review Home Health, acute, post-acute, outpatient, and pharmacy authorization requests while consistently meeting quality, productivity, and turnaround time expectations. • Build strong partnerships with the H

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