Medical Director, Utilization Management (Home Health, Acute & Post-Acute)

Clover Health
United States
Workplace: RemoteFull timeUSD 242,300 - 315,000 annuallyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 5+ yearsEducation: professionalSkills: ["Communication","Relationship building","Clinical judgment","Peer-to-peer collaboration","Evidence-based decision-making"]

Lead utilization management for Home Health by reviewing complex authorization requests across episodic and per-visit services for medical necessity. Use CMS Home Health regulations, Medicare Benefit Policy Manual, NCD/LCD, Milliman Care Guidelines, and Clover clinical policies to drive consistent, evidence-based decisions. Serve as the primary physician reviewer and escalation point, partner with RN leads and nurses, conduct peer-to-peer discussions, and support calibration, quality initiatives, and guideline development.

Loading

Loading job details...

Preparing the role view and application actions.

FursaFursa
Clover Health
Clover Health
1 day ago

Medical Director, Utilization Management (Home Health, Acute & Post-Acute)

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 4 hours agoStatus: Live

Job Summary

Lead utilization management for Home Health by reviewing complex authorization requests across episodic and per-visit services for medical necessity. Use CMS Home Health regulations, Medicare Benefit Policy Manual, NCD/LCD, Milliman Care Guidelines, and Clover clinical policies to drive consistent, evidence-based decisions. Serve as the primary physician reviewer and escalation point, partner with RN leads and nurses, conduct peer-to-peer discussions, and support calibration, quality initiatives, and guideline development.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Director level

Key Responsibilities

  • •Support and participate in Utilization Management processes across the continuum of care.
  • •Review Home Health, acute inpatient, post-acute, outpatient, and pharmacy authorization requests for medical necessity.
  • •Serve as the primary physician reviewer and escalation point for complex Home Health medical necessity determinations.
  • •Conduct peer-to-peer discussions with physicians and providers to facilitate appropriate care decisions.
  • •Mentor utilization management nurses and support reviewer calibration, quality initiatives, and the development of utilization policies and clinical guidelines.

Pay and Benefits

Salary: USD 242,300 - 315,000 annually
Equity and Bonus:Equity
Perks:Health InsuranceDentalVision401kRemote WorkPaid ParentalLearning Budget

Key Requirements

  • •MD or DO degree with board certification in a relevant specialty and an unrestricted U.S. medical license.
  • •5+ years of clinical experience, including Utilization Management and Medicare Advantage experience.
  • •Expertise reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria.
  • •Experience reviewing acute, post-acute, outpatient, and/or pharmacy services and collaborating across interdisciplinary teams.
  • •Strong communication skills for peer-to-peer discussions and relationship-building to improve member outcomes.
Experience:5+ yearsUtilization managementMedicare AdvantageHome healthAcute carePost-acute care
Education:Professional (JD, MD, etc.)
Skills:CommunicationRelationship buildingClinical judgmentPeer-to-peer collaborationEvidence-based decision-making
Licenses:Unrestricted U.S. medical licenseBoard certified
Languages:English

Company Brief

Clover Health
Clover Health is a technology-driven health insurance company offering Medicare Advantage plans that combine clinical care coordination, data analytics, and value-based care to improve outcomes and reduce costs for seniors.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: Jersey City, United States
Founded: 2014
WebsiteLinkedIn