Clover Health

Medical Director

• 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

Medical Director, Utilization Management