This role will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. The physician will utilize local and national CMS Coverage Determinations, Milliman Care Guidelines, reviews as provided by our vendor's nurse reviewers along with Clover Health’s standard medical guidelines to determine whether a request for services demonstrates medical necessity or if an alternate treatment plan should be employed; Clover Health’s Medical Management Committee provides oversight of the utilization review process and ensures that all decisions comply with accepted standards for determination of medical necessity.
As a Utilization Management Medical Director, you will:
- Participate in and support the Clover Health Utilization Management processes
- Evaluate outpatient referral requests and inpatient direct admissions within established timelines
- Perform peer to peer discussions with providers
- Discuss specialty care with community specialists to ensure continuity of care and to facilitate the delivery of health care
- Provide mentoring, and coaching to physician and UM nurses to strengthen Utilization Management effectiveness
- Support the ongoing development of Clover Health’s clinical guidelines
- Identify and develop resources and educational tools based on utilization trends
- Maintain credentials as required for employment with Clover Health
- Assist in screening, interviewing and evaluating healthcare providers
You will love this job if:
- You are dedicated to improving the quality of life of members by providing superior, personalized, patient-centered care.
- You are excited by big, complicated problems and try to solve them with creative, elegant, and simple solutions. You have a natural intellectual curiosity that drives you to find out how things work and if they can work better.
- You value collaboration and feedback. You can communicate your vision in clear terms — to your peers as well as outside of your immediate team. You are willing and able to help your teammates grow by demonstrating best practices, providing (and receiving) respectful and constructive feedback, and sharing your unique insights with everyone.
- You enjoy working in a fluid environment, defining and owning priorities that adapt to our larger goals. You can bring clarity to ambiguity while remaining open-minded to new information that might change your mind.
- You are happy to fill in the gaps to reach a goal where necessary, even if it does not always fit your job description.
- You have a genuine interest in what good technology can do to help people and have a positive attitude about tackling hard problems in an important industry.
You should get in touch if:
- You are a MD or DO
- You have a valid, unrestricted license to practice medicine in a US State
- You are Board Certified, Internal Medicine, Family Medicine, Emergency Medicine or similar speciality
- You have clinical experience of at least 5 years with inpatient experience
- You have Utilization management/review experience
- You have Medicare Advantage experience
- You are an excellent communication and interpersonal skills
- You have proficiency with computers/technology