Medical Director, Utilization Management (UM) & Quality Assurance (QA)

Summary

Join Clover Health as a Medical Director and play a key leadership role in shaping clinical review strategies, guidelines, and processes within our Medicare Advantage plan. You will review medical decision-making, support quality assurance, coach clinical decision-makers, and perform data analysis. This full-time position reports to the Chief Medical Officer and involves collaborating with providers and contributing to quality improvement initiatives. Success in this role involves advanced decision-making, establishing quality assurance processes, and driving innovation in clinical review practices. The ideal candidate is an MD or DO with a valid, unrestricted US medical license and significant clinical experience.

Requirements

• Be an MD or DO
• Have a valid, unrestricted license to practice medicine in a US State
• Have clinical experience of at least 5 years with inpatient experience
• Have Utilization management/review experience
• Have proficiency with computers/technology

Responsibilities

• Review ongoing sample cases of medical decision-making by vendors and delegated providers
• Support QA team in evaluating and improving UM and Appeal processes
• Coach and train clinical decision makers to improve proper selection and application of medical necessity guidelines
• Perform in-depth trend data analysis and develop quarterly performance reports
• Support the Senior Medical Director by preparing reports for the Medical Management Committee, MMC, and Quality Improvement Committee
• Identify and develop opportunities for innovation to increase service and clinical quality
• Lead or contribute to quality improvement committees and teams
• Serve on quality improvement teams as a leader, participant or consultant
• Participate in company efforts to improve quality metrics such as STARS and HEDIS measures; member and provider satisfaction
• Execute additional QA responsibilities as assigned by the CMO
• Maintain credentials as required for employment with Clover Health
• Collaborate with providers to ensure consistent and standardized decision-making through periodic case reviews

Preferred Qualifications

• Be Board Certified, Internal Medicine, Family Medicine, Emergency Medicine or similar specialty
• Have Medicare Advantage experience
• Thrive in collaborative, cross-functional settings

Benefits

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