Clover Health · 20 hours ago
Medical Director, Payment Integrity & Utilization Management
United States
Full-time
Remote
Mid, Senior Level
$270K/yr - $330K/yr
5+ years expClover Health is reinventing health insurance with a focus on keeping members healthier through an integrated technology platform. They are seeking a detail-oriented Medical Director specializing in Payment Integrity and Utilization Management to perform medical record reviews, ensure appropriate care and payment accuracy, and lead quality improvement initiatives.
Health CareHealth InsuranceHospitalMedical
Responsibilities
Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines
Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided
Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines
Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives
Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends
Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization
Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making
Qualification
Required
You are an MD or DO with a valid, unrestricted license to practice medicine in a US State
You are Board Certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine
You have at least 5 years of clinical experience, including inpatient experience
You have strong experience in Payment Integrity and Utilization Management/Review and a solid understanding of Medicare Advantage
You have experience or expertise with peer review committees
You are extremely detail-oriented and meticulous, and you genuinely enjoy digging into medical records to find the 'needle in the haystack'
You possess discerning clinical judgment and an investigative, problem-solving mindset
You thrive in collaborative, cross-functional settings and have strong proficiency with technology
Benefits
Competitive base salary and equity opportunities
Performance-based bonus program
401k matching
Regular compensation reviews to recognize and reward exceptional contributions
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
Remote-first culture, enabling collaboration with global teams
Paid parental leave for all new parents
Company
Clover Health
Clover is a healthcare technology company helping members live their healthiest lives with its Medicare Advantage plans.
501-1000 employees
Funding
Current Stage
Public CompanyTotal Funding
$1.62BKey Investors
GreenoaksSequoia CapitalFirst Round Capital
2021-11-17Post Ipo Equity· $300M
2021-01-08Post Ipo Equity· $400M
2021-01-08IPO
Leadership Team
Andrew Toy
Chief Executive Officer and Board Member (NASDAQ : CLOV)
Jamie Reynoso
Chief Executive Officer
Recent News
Fierce Healthcare
2026-01-19
2026-01-16
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