Medical Director, Utilization Management

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most. 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. As a Medical Director, Utilization Management, you will: • Participate and support the Clover Health Utilization Management processes. • Support Quality improvement initiatives for Clover members. • Review Utilization Management authorization request 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. Success in this role looks like: • How is success measured in the first 90 days? • Successfully completes all required new hire training modules and certifications • Demonstrates a foundational understanding of Clover Health's medical policies, guidelines, and utilization management processes • Begins to independently review cases with increasing efficiency and accuracy, requiring minimal oversight • Establishes positive working relationships with team members and key stakeholders • How is success measured in the first 6 months? • Consistently meets or exceeds productivity targets for case reviews and determinations. • Maintains a high level of accuracy in medical necessity determinations and documentation. • Actively participates in team meetings and contributes to process improvement discussions. • Demonstrates a comprehensive understanding of complex medical cases and escalates issues appropriately. • Provides clear and concise rationales for medical decisions, adhering to regulatory and compliance standards. • How will success be measured in the future? • Sustained high performance in productivity, accuracy, and adherence to medical policies and guidelines. • Proactive identification of opportunities to improve utilization management processes and patient outcomes. • Mentorship and support of junior medical directors or clinical staff. • Contribution to the development and refinement of medical policies and clinical programs. • Ongoing professional development and maintenance of medical licensure and board certifications. • Positive feedback from internal and external stakeholders regarding clinical judgment and collaboration. You should get in touch if: • You have an MD or DO degree. • You have Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty. • You have a valid, unrestricted license to practice medicine in a U.S. state. • You have a minimum of five years of clinical experience. • You have at least one year of experience as a Utilization Management reviewer. • You have Medicare Advantage exper