Lead Medical Director, Utilization Management

The posting, as Clover Health wrote it

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 Utilization Management team supports access to appropriate care through timely, evidence-based medical necessity decisions and clear clinical policies. The Lead Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. The Lead 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 Lead Medical Director, you will

• Complete assigned prior authorization, concurrent, retrospective, and other UM cases with sound clinical judgment and within established turnaround expectations.
• Ensure clinical decisions are consistent with applicable medical necessity criteria and support the clinical integrity of UM reviews.
• Manage a team of Utilization Managerment Medical Directors.
• Review complex or escalated cases and obtain appropriate specialty consultation when needed.
• Develop, review, and maintain clinical policies, pharmacy policies, medical necessity criteria, and UM procedures with clinical experts and operational teams; monitor emerging evidence and recommend updates.
• Chair the Utilization Management Committee by setting agendas, presenting policy recommendations and utilization trends, documenting decisions, and following through on committee actions.
• Serve on the Credentialing Committee and provide physician input on credentialing matters, provider qualifications, and clinical concerns.
• Contribute to the Quality Committee by identifying trends in care quality, access, and outcomes and recommending opportunities for improvement.
• Participate in peer-to-peer discussions, appeals, and provider education as needed, communicating clinical decisions clearly and respectfully.
• Use audit findings, case reviews, appeals, complaints, and UM performance data to identify variation and improve policies, clinical practice, and workflows.
• Partner with care management, quality, compliance, network, pharmacy, and operations teams on issues that cross clinical programs.
• Support regulatory and accreditation readiness through appropriate clinical documentation, committee records, and corrective actions within the role’s scope.
• Advise organizational leaders on UM strategy, clinical risks, and opportunities to improve the member and provider experience.

Success in this role l
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opment funding, and regular performance feedback and reviews.

Additional Perks

• 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
• And much more!

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, perspectives, opinions, 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.

#LI-REMOTE

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.
Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.

A reasonable estimate of the base salary range for this role is:
$320,000 — $340,000 USD