Medical Director, Utilization Management – Part Time, Weekends
Clover Health
part-time
Posted on:
Location Type: Remote
Location: United States
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Job Level
About the role
- The Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness.
- The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health’s medical policies reviews to determine medical necessity or if an alternate treatment plan is required for our members.
- Successfully completes all required new hire training modules and certifications
- Demonstrates a foundational understanding of Clover Health's medical policies, guidelines, and utilization management processes
- Begins to independently review cases with increasing efficiency and accuracy, requiring minimal oversight
- Establishes positive working relationships with team members and key stakeholders
- Consistently meets or exceeds productivity targets for case reviews and determinations
- Maintains a high level of accuracy in medical necessity determinations and documentation
- Actively participates in team meetings and contributes to process improvement discussions
- Demonstrates a comprehensive understanding of complex medical cases and escalates issues appropriately.
Requirements
- You have an MD or DO degree.
- You have Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or a related specialty.
- You have a valid, unrestricted license to practice medicine in a U.S. state.
- You have a minimum of five years of clinical experience.
- You have at least one year of experience as a Utilization Management reviewer.
- You have Medicare Advantage experience.
- You are dedicated to improving members’ quality of life by providing superior, personalized, patient-centered care.
- You have a genuine interest in leveraging technology to help people and maintain a positive attitude toward tackling important industry challenges.
Benefits
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Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical necessity determinationutilization managementcase reviewclinical experienceMedicare Advantagemedical policy reviewtreatment plan evaluationdocumentation accuracypatient-centered careMilliman Care Criteria
Soft Skills
interpersonal skillsteam collaborationprocess improvementcommunication skillsproblem-solvingattention to detailindependenceefficiencyaccuracypositive attitude
Certifications
MDDOBoard Certification in Internal MedicineBoard Certification in Family MedicineBoard Certification in Emergency Medicine