Medical Director, Utilization Management – Home Health, Acute & Post-Acute
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Job Description
Medical Director guiding utilization management for Clover Health, a data-driven health insurer. Reviewing Home Health and broader care authorizations to ensure evidence-based Medicare member care.
Responsibilities:
- Participate in and support Clover Health Utilization Management processes.
- Review authorization requests for Home Health, acute inpatient, post-acute, outpatient, and pharmacy services for medical necessity.
- Serve as the primary physician reviewer for complex Home Health authorization requests requiring Medical Director determination.
- Review episodic and per-visit Home Health authorization requests using CMS regulations, the Medicare Benefit Policy Manual, NCD/LCDs, and Clover clinical guidelines.
- Evaluate acute inpatient, post-acute, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests within established turnaround times.
- Apply evidence-based medical necessity criteria and promote appropriate utilization across service lines.
- Serve as the physician escalation point for complex Home Health determinations.
- Perform peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other providers.
- Partner with the Home Health RN Lead to ensure consistent application of coverage criteria.
- Mentor and educate Utilization Management nurses on complex Home Health cases.
- Participate in reviewer calibration sessions, quality initiatives, and ongoing education.
- Support development of clinical guidelines, utilization management policies, and Home Health review criteria.
- Collaborate with Home Health agency partners to promote evidence-based care and improve documentation quality.
- Support quality improvement initiatives for Clover members.
- Become proficient in UM workflows and independently meet quality, productivity, and turnaround expectations.
- Provide clinical leadership, improve utilization management performance, and support positive member outcomes.
Requirements:
- MD or DO degree
- Board certification in a relevant specialty
- Unrestricted U.S. medical license
- 5+ years of clinical experience, including Utilization Management and Medicare Advantage experience
- Expertise reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria
- Experience reviewing acute, post-acute, outpatient, and/or pharmacy services
- Ability to collaborate across interdisciplinary teams
- Effective communication and peer-to-peer discussion skills
- Relationship-building skills and passion for improving member outcomes through innovation and technology
Benefits:
- Competitive base salary
- Equity opportunities
- Performance-based bonus program
- 401k matching
- Regular compensation reviews
- Comprehensive medical, dental, and vision coverage
- No-Meeting Fridays
- Monthly company holidays
- Mental health resources
- Generous flexible time-off policy
- Remote-first culture supporting collaboration and flexibility
- Learning programs
- Mentorship
- Professional development funding
- Regular performance feedback and reviews
- 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
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