Remote Lead Medical Director, Utilization Management

Clover Health; United States; Remote; USD 320.000 - 340.000; Vollzeit

Benefits dieser Stelle

Equity opportunities

401k matching

Performance-based bonus

Remote-first culture

Professional development support

Zusammenfassung

Clover Health is seeking a Lead Medical Director, Utilization Management, to guide medical necessity decisions for outpatient referrals and inpatient admissions. You will lead a team, develop and update clinical policies, and ensure decisions reflect evidence-based standards while collaborating with cross-functional partners.

You will advise on UM strategy, participate in committees, and drive quality improvements, all within a remote-first framework supporting US operations.

Qualifikationen

• MD or DO degree with active, unrestricted medical license.
• Board certified in a relevant clinical specialty.
• 5+ years clinical practice in utilization management or medical necessity review.
• 5+ years leadership experience directly managing a clinical team.
• Strong understanding of evidence-based guidelines, coverage policy, quality improvement, and regulatory needs.

Aufgaben

• Complete assigned prior authorization, concurrent, retrospective, and other UM cases with sound clinical judgment and turnaround expectations.
• Ensure clinical decisions align with medical necessity criteria and UM reviews.
• Manage a team of Utilization Management Medical Directors.
• Review complex cases and obtain appropriate specialty consultation.
• Develop and maintain clinical and pharmacy policies and UM procedures with experts.
• Chair the Utilization Management Committee and present recommendations and trends.

Kenntnisse

MD or DO

Leadership

Clinical judgment

Communication

Board certification

Ausbildung

MD/DO degree

Active medical license

Board certification

Jobbeschreibung

Clover Health is seeking a Lead Medical Director, Utilization Management, to guide medical necessity decisions for outpatient referrals and inpatient admissions. You will lead a team, develop and update clinical policies, and ensure decisions reflect evidence-based standards while collaborating with cross-functional partners.

You will advise on UM strategy, participate in committees, and drive quality improvements, all within a remote-first framework supporting US operations.