Medical Director, Utilization Management

  • Clover Health
  • Remote
  • Oct 27, 2021
Physician Emergency Medicine Family Medicine Internal Medicine

Job Description

Clover is reinventing health insurance by working to keep people healthier.

Clover is a Medicare Advantage plan working to develop deeper insights to drive better outcomes for our members through our integrated technology platform. We rely on our abilities to integrate standard health plan data (eligibility, provider network, claims, authorizations, etc.) with clinical information from provider health information systems.

We’re looking to hire a Utilization Management Medical Director to support our growing operations. This role will be a per diem position (20 hours weekly) responsible for the evaluation of all outpatient referrals for Part B Step Therapy Reviews as well as some inpatient reviews for  medical appropriateness. The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health’s medical policies reviews, and Step Therapy Guidance to determine medical necessity or if an alternate treatment plan is required for our members. Clover Health’s Medical Management Committee provides oversight of the utilization review process and ensures that all decisions comply with accepted standards for determination of medical necessity.

As a Utilization Management Medical Director, you will:

  • Participate and support the Clover Health Utilization Management processes.
  • Evaluate outpatient referral requests and inpatient direct admissions within established timelines.
  • Perform peer to peer discussions and build collaborative relationships with community and hospital Providers.
  • Discuss specialty care with community specialists to ensure continuity of care and facilitate the continuum of health care.
  • Provide mentoring, and coaching to UM nurses to strengthen Utilization Management effectiveness.
  • Support the ongoing development of Clover Health’s clinical guidelines and policies.
  • Identify and develop resources and educational tools based on utilization trends.
  • Maintain credentials as required for employment with Clover Health.
  • Assist in screening, interviewing and evaluating healthcare providers.

You will love this job if:

  • You are dedicated to improving the quality of life of members by providing superior, personalized, patient-centered care.
  • You are excited by big, complicated problems and try to solve them with creative, elegant, and simple solutions. You have a natural intellectual curiosity that drives you to find out how things work and if they can work better.
  • You value collaboration and feedback. You can communicate your vision in clear terms — to your peers as well as outside of your immediate team. You are willing and able to help your teammates grow by demonstrating best practices, providing (and receiving) respectful and constructive feedback, and sharing your unique insights with everyone.
  • You enjoy working in a fluid environment, defining and owning priorities that adapt to our larger goals. You can bring clarity to ambiguity while remaining open-minded to new information that might change your mind.
  • You are happy to fill in the gaps to reach a goal where necessary, even if it does not always fit your job description.
  • You have a genuine interest in what good technology can do to help people and have a positive attitude about tackling hard problems in an important industry.

You should get in touch if:

  • You are a MD or DO.
  • You have a valid, unrestricted license to practice medicine in a US State.
  • You are Board Certified, Internal Medicine, Family Medicine, Emergency Medicine or similar speciality.
  • You have clinical experience of at least 5 years with inpatient experience.
  • You have Utilization management/review experience.
  • You have Medicare Advantage experience.
  • You have proficiency with computers/technology.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.

About Clover: We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.

From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.