Remote opportunity at
Clover HealthMedical Director, Utilization Management
Clover Health operates as a healthcare company focused on delivering affordable and accessible healthcare plans tailored for older adults. The organization utilizes data analytics and proprietary…
Career Tools
About This Role
Clover Health operates as a healthcare company focused on delivering affordable and accessible healthcare plans tailored for older adults. The organization utilizes data analytics and proprietary technology, including the Clover Assistant platform, to equip physicians with comprehensive patient histories and support informed medical choices. To support these operations, the company seeks a Medical Director, Utilization Management to evaluate inpatient direct admissions and outpatient referrals to determine medical appropriateness. In this…
Job Description
Clover Health operates as a healthcare company focused on delivering affordable and accessible healthcare plans tailored for older adults. The organization utilizes data analytics and proprietary technology, including the Clover Assistant platform, to equip physicians with comprehensive patient histories and support informed medical choices. To support these operations, the company seeks a Medical Director, Utilization Management to evaluate inpatient direct admissions and outpatient referrals to determine medical appropriateness.
In this position, the physician applies Local and National Medicare Coverage Determinations, Milliman Care Criteria, and internal medical policies to review authorization requests. Duties involve handling post-acute care, pharmacy, and referral evaluations within designated timeframes, while engaging in peer discussions with hospital and community providers. Additionally, the role involves mentoring utilization management nursing personnel, contributing to quality improvement programs, and participating in the refinement of clinical guidelines.
This role suits an experienced medical professional holding an active doctor of medicine or osteopathic medicine degree who possesses a background in Medicare Advantage and clinical practice. Candidates should demonstrate readiness to handle complex medical case evaluations, collaborate effectively with clinical and administrative colleagues, and adhere to established compliance standards. The position operates within a remote-first work environment, allowing staff members to collaborate across locations while maintaining access to professional growth initiatives and employee support benefits.
Responsibilities
- Participate in and support utilization management processes
- Support quality improvement initiatives for health plan members
- Review authorization requests for medical necessity across outpatient referrals, inpatient direct admissions, post-acute referrals, and pharmacy within established timelines
- Conduct peer-to-peer discussions and build collaborative relationships with community and hospital providers
- Provide mentoring and coaching to utilization management nurses to strengthen effectiveness
- Support the ongoing development of clinical guidelines and policies
Requirements
- Minimum of five years of clinical experience
- At least one year of experience as a utilization management reviewer
- Medicare Advantage experience
- Valid, unrestricted license to practice medicine in a U.S. state
Qualifications
- MD or DO degree
- Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty
Benefits
- Competitive base salary and equity opportunities
- Performance-based bonus program
- 401k matching
- Comprehensive medical, dental, and vision coverage
- No-Meeting Fridays
- Monthly company holidays
- Access to mental health resources
- Flexible time-off policy
- Employee Stock Purchase Plan offering discounted equity opportunities
- Reimbursement for office setup expenses
- Monthly cell phone and internet stipend
- Paid parental leave for all new parents
- Learning programs, mentorship, and professional development funding
Frequently Asked Questions
Answers are based only on the employer’s listing; where it doesn’t say, neither do we.
Is this a remote position?
Yes, the posting notes that the company maintains a remote-first culture.
What is the employment type?
The employment type is full-time.
What salary is offered for this role?
The salary is not specified in the job posting.
What are the core educational and certification prerequisites?
Applicants must hold an MD or DO degree, a board certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty, and an active, unrestricted medical license in a U.S. state.
Sample Interview Questions
AI-generated questions tailored to this specific role — a preview of the full practice set.