Utilization Management Medical Director at Clover Health
San Francisco, CA, US
Clover Health is driving down costs and producing improved health outcomes with a unique health insurance plan. We use sophisticated analytics and custom software to direct our own clinical staff to proactively fill in gaps in the care of our members. We have a proven model we're scaling out.

We're focusing on elderly and low-income patients that stand to benefit from our model the most. This puts us in a position to make a major dent in healthcare expense in the United States and reverse an unsustainable, decades-long spending trend.

The Job:

Working in conjunction with the Chief Medical Officer, the Medical Director oversees medical care for products and services and supervises the health care needs of the membership. Serves as a medical manager and policy advisor to Clover and the Chief Medical Officer. Is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, etc. Assists (as determined by the plan Chief Medical Officer) in short and long range program planning, total quality management (quality improvement) and external relationships. Reports all issues of clinical quality management to the Chief Medical Officer. Collaborates with the Chief Medical Officer, and other medical directors, on national medical policies and carries out national medical policies in collaboration with the CEO.

Job Description:

Responsible and accountable to the Chief Medical Officer for helping to manage medical costs and assuring appropriate health care delivery for health plans, products and services. Performs Utilization Management and Medical Necessity reviews. Reviews member and provider appeals and communicates with Independent Review Entities. Reports organizationally to the Chief Medical Officer.
Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for inpatient, outpatient, preventive and wellness programs.
Assists in designing and implementing health medical policies, goals and objectives.
Responsible for and assists with the development of budgets, staffing plans and medical loss ratio projections, assuring the adequate allocation of resources to the medical management functions.
Responsible and accountable for implementing the Utilization/Cost Management Program and Clinical Quality Improvement Program. Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives.
Assists the Chief Medical Officer with activities to promote positive community relations.
Assures plan conformance with legal and regulatory requirements.
Assists the Chief Medical Officer in creating and maintaining a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks.
Assists the Chief Medical Officer in designing and implementing corrective action plans to address issues and improve plan and network managed care performance. Collaborates with Chief Medical Officer and VP of Provider Alignment in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes. Participates actively in provider recruitment.
Participates in policy review, performs analysis and makes recommendations.
Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs and other sources.
Provides periodic written and verbal reports and updates as required in the Quality Management Program description.
Prepares for site visits and responds to accrediting and regulatory agency feedback.
Supports pre-admission review, utilization management, and concurrent and retrospective review process.
Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.
Conducts quality improvement and outcomes studies as directed by the state Departments of Health, the Quality Management Committee, Peer Review Committee and management. Reports findings. Participates in the grievance process with the Chief Medical Officer, ensuring an appropriate outcome for all members.
Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
Assists the contracting process of providers, hospitals, ancillary providers, and emergency and other support services, and evaluates the medical aspects of provider contracts.
Participates in key marketing activities and presentations.
Promotes wellness and ensures programs of prevention, education and outreach to members and providers consistent with company’s mission, vision and values.
Maintains up-to-date knowledge of new information and technologies in medicine and their application to the health plan.
Performs and oversees in-service staff training and education of professional staff.
Represents Clover at medical group meetings, conferences, etc.
Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.
Participates in key marketing activities and presentations, as necessary, to assist the marketing effort.
Performs other duties as requested or assigned.

Desired Skills, Experience, and Education:

Management skills to meet the organizational goals
Excellent communications skills to interface with providers, staff, and management
Able to manage multiple priorities and deadlines in an expedient and decisive manner
Able to manage difficult peer situations arising from medical care review
Appreciation of cultural diversity and sensitivity towards target population
Knowledge of HEDIS and NCQA requirements preferred
Knowledge of medical, quality improvement and UM practices in a managed care environment. Knowledge of regulatory and accreditation agencies and requirements
5 years of clinical experience in the practice of medicine
Emergency room physician or those well-versed in admissions criteria and guidelines preferred
Continuing education to remain current in medical and management areas
Masters in Public Health, MBA, or MA preferred
Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management preferred
Unrestricted License in Plan State as a Doctor of Medicine or a Doctor of Osteopathy. Active license to practice medicine issued by the State Board of Licensure or the State Board of Osteopathic Examiners. Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS)

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.