Medical Director, Utilization Management jobs in United States
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Clover Health · 4 months ago

Medical Director, Utilization Management

positionUnited States
timeFull-time
remoteRemote
senioritySenior Level
money$207K/yr - $253K/yr
date5+ years exp

Clover Health is committed to providing high-quality healthcare plans for America’s seniors, focusing on preventive care through innovative technology. The Medical Director, Utilization Management, will evaluate outpatient referrals and inpatient admissions for medical appropriateness, utilizing various guidelines to ensure effective patient care and support utilization management processes.

Health CareHealth InsuranceHospitalMedical

Responsibilities

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

Qualification

MDDO degreeBoard CertificationUtilization Management experienceMedicare Advantage experienceClinical experienceTechnology proficiencyMentoring skillsCollaboration skills

Required

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 experience
You are dedicated to improving members' quality of life by providing superior, personalized, patient-centered care
You have a genuine interest in leveraging technology to help people and maintain a positive attitude toward tackling important industry challenges

Benefits

Competitive base salary and equity opportunities
Performance-based bonus program
401k matching
Regular compensation reviews
Comprehensive medical, dental, and vision coverage
No-Meeting Fridays
Monthly company holidays
Access to mental health resources
Generous flexible time-off policy
Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
Reimbursement for office setup expenses
Monthly cell phone & internet stipend
Paid parental leave for all new parents

Company

Clover Health

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Glassdoor3.4
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Clover is a healthcare technology company helping members live their healthiest lives with its Medicare Advantage plans.
dateFounded in 2014
location
Nashville, Tennessee, USA
people-size501-1000 employees
web-link
http://cloverhealth.com

Funding

Current Stage
Public Company
Total Funding
$1.62B
Key Investors
GreenoaksSequoia CapitalFirst Round Capital
2021-11-17Post Ipo Equity· $300M
2021-01-08Post Ipo Equity· $400M
2021-01-08IPO

Leadership Team

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Andrew Toy
Chief Executive Officer and Board Member (NASDAQ : CLOV)
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Jamie Reynoso
Chief Executive Officer
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Recent News

GlobeNewswire
Clover Health to Participate in Upcoming J.P. Morgan 2026 Healthcare Conference
2025-12-17
Clover Health Receives $1.2 Billion Valuation
2025-12-10
GlobeNewswire
From Hype to P&L: Hospitals Now Buying AI That Pays
2025-12-08
Company data provided by crunchbase