The Utilization Management (UM) team is made up of experienced physicians and clinicians who work together to ensure Clover members receive medically appropriate, evidence-based care while optimizing quality and resource utilization. As the Medical Director, Utilization Management, you will play a critical role in supporting timely utilization decisions across the continuum of care, with a primary focus on Home Health services while also reviewing acute, post-acute, outpatient, and pharmacy authorization requests.
In this role, you will serve as the physician leader for Home Health utilization management, reviewing complex authorization requests for episodic and per-visit services to determine medical necessity. Leveraging CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines, and Clover Health clinical policies, you will help ensure consistent, evidence-based decision-making that supports high-quality member care. You'll partner closely with the Home Health RN Lead, Utilization Management nurses, providers, and cross-functional teams to improve clinical outcomes, promote appropriate utilization, and advance Clover's commitment to delivering exceptional Home Health services.
As a Medical Director, Utilization Management, you will:
- 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 both episodic and per-visit Home Health authorization requests using CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines.
- Evaluate acute inpatient admissions, post-acute services, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests within established turnaround times.
- Apply evidence-based medical necessity criteria while promoting appropriate utilization across all service lines.
- Serve as the physician escalation point for complex Home Health medical necessity determinations submitted by the Utilization Management nursing team.
- Perform peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other providers to facilitate appropriate care decisions.
- Partner with the Home Health RN Lead to ensure consistent interpretation and application of Home Health coverage criteria.
- Mentor and educate Utilization Management nurses on complex Home Health cases, including episodic and per-visit review methodologies.
- Participate in Home Health reviewer calibration sessions, quality initiatives, and ongoing education to improve consistency and decision quality.
- Support the ongoing development of Clover Health clinical guidelines, utilization management policies, and Home Health review criteria.
- Collaborate with Home Health agency partners to promote evidence-based care, improve documentation quality, and support optimal member outcomes.
- Support quality improvement initiatives for Clover members.
Success in this role looks like:
Within your first 90 days, you will:
- Become fully proficient in Clover's Utilization Management workflows, Home Health review processes, CMS regulations, and Medicare coverage criteria through successful onboarding and training.
- Independently review Home Health, acute, post-acute, outpatient, and pharmacy authorization requests while consistently meeting quality, productivity, and turnaround time expectations.
- Build strong partnerships with the Home Health RN Lead, Utilization Management nurses, providers, and cross-functional teams while serving as a trusted clinical resource for complex cases.
Within your first 6 months, you will:
- Be recognized as a subject matter expert in Home Health utilization management, providing consistent, evidence-based medical necessity determinations across all service lines.
- Lead effective peer-to-peer discussions and contribute to reviewer education, calibration sessions, and quality improvement initiatives that strengthen clinical consistency.
- Partner with clinical and operational leaders to enhance reviewer quality, improve utilization management performance, and support positive member outcomes.
As you continue to grow in the role, you will:
- Drive continuous improvement of Clover's Home Health utilization management program through clinical leadership and evidence-based decision-making.
- Influence the development of utilization management policies, clinical guidelines, and best practices that improve quality, consistency, and operational excellence.
- Serve as a trusted physician leader who collaborates across teams to optimize member outcomes, provider partnerships, and resource utilization.
You should get in touch if:
- You have an MD or DO degree, are board certified in a relevant specialty, and hold an unrestricted U.S. medical license.
- You have 5+ years of clinical experience, including Utilization Management and Medicare Advantage experience.
- You have expertise reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria; experience serving as a Medical Director or physician reviewer is preferred.
- You have experience reviewing acute, post-acute, outpatient, and/or pharmacy services and enjoy collaborating across interdisciplinary teams to deliver high-quality, evidence-based care.
- You are an effective communicator who thrives in peer-to-peer discussions, values relationship building, and is passionate about improving member outcomes through innovation and technology.
Benefits Overview:
- Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
- Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
- Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
- Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development 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.
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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.
