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:

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