Lead 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 Utilization Management team supports access to appropriate care through timely, evidence-based medical necessity decisions and clear clinical policies. The Lead Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. The Lead 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 Lead Medical Director, you will: • Complete assigned prior authorization, concurrent, retrospective, and other UM cases with sound clinical judgment and within established turnaround expectations. • Ensure clinical decisions are consistent with applicable medical necessity criteria and support the clinical integrity of UM reviews. • Manage a team of Utilization Managerment Medical Directors. • Review complex or escalated cases and obtain appropriate specialty consultation when needed. • Develop, review, and maintain clinical policies, pharmacy policies, medical necessity criteria, and UM procedures with clinical experts and operational teams; monitor emerging evidence and recommend updates. • Chair the Utilization Management Committee by setting agendas, presenting policy recommendations and utilization trends, documenting decisions, and following through on committee actions. • Serve on the Credentialing Committee and provide physician input on credentialing matters, provider qualifications, and clinical concerns. • Contribute to the Quality Committee by identifying trends in care quality, access, and outcomes and recommending opportunities for improvement. • Participate in peer-to-peer discussions, appeals, and provider education as needed, communicating clinical decisions clearly and respectfully. • Use audit findings, case reviews, appeals, complaints, and UM performance data to identify variation and improve policies, clinical practice, and workflows. • Partner with care management, quality, compliance, network, pharmacy, and operations teams on issues that cross clinical programs. • Support regulatory and accreditation readiness through appropriate clinical documentation, committee records, and corrective actions within the role’s scope. • Advise organizational leaders on UM strategy, clinical risks, and opportunities to improve the member and provider experience. Success in this role looks like: • In the first 90 days, learn UM policies, workflows, committee processes, and documentation expectations, and begin completing assigned reviews. • In the first 6 months, complete reviews consistently and on time, contribute to committee work, and identify relevant case or policy trends. • Over time, support clear and current policies, consistent clinical decisions, effective committee follow-through, and measurable improvements in quality, access, or outcomes. You should get in touch if: • You have an MD or DO degree and an active, unrestricted medical license. • You are board certified in a relevant clinical specialty. • You have at least 5 years of clinical practice experience in utilization management or medical necessity review. • You have at least 5 years of leadership