Behavioral Health Medical Director, Psychiatrist
Elevance Health
Medical Director, Utilization Management
Clover Health
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $207,000 - $253,000 per year
Job Level
Lead
About the role
- Evaluate all outpatient referrals and inpatient direct admissions for medical appropriateness
- Utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, and Clover Health medical policies to determine medical necessity or recommend alternate treatment plans
- Participate in and support Clover Health Utilization Management processes
- Support quality improvement initiatives for Clover members
- Review Utilization Management authorization requests for medical necessity within established timelines
- Evaluate authorizations for outpatient referral, inpatient direct admissions, post-acute referral, and pharmacy
- Perform peer-to-peer discussions and build collaborative relationships with community and hospital providers
- Provide mentoring and coaching to UM nurses to strengthen Utilization Management effectiveness
- Support the ongoing development of Clover Health’s clinical guidelines and policies
- Maintain required medical credentials and board certifications
Requirements
- MD or DO degree
- Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty
- Valid, unrestricted license to practice medicine in a U.S. state
- Minimum of five years of clinical experience
- At least one year of experience as a Utilization Management reviewer
- Medicare Advantage experience
- Dedicated to improving members’ quality of life by providing superior, personalized, patient-centered care
- Genuine interest in leveraging technology to help people and a positive attitude toward industry challenges
- Maintain credentials as required for employment with Clover Health
