Medical Director, Utilization Management

MD or DO degree Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty Valid, unrestricted license to practice medicine in a U.S. state Minimum of five years of clinical experience At least one year of experience as a Utilization Management reviewer Medicare Advantage experience

Evaluate outpatient referrals and inpatient direct admissions for medical appropriateness. Utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, and Clover Health’s medical policies to determine medical necessity. Participate and support Clover Health Utilization Management processes. Support Quality improvement initiatives for Clover members. Review Utilization Management authorization requests 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. Support the ongoing development of Clover Health’s clinical guidelines and policies. Maintain credentials as required for employment with Clover Health.