Clover Health - Medical Director, Payment Integrity & Utilization Management
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Requirements
• Strong background in Payment Integrity (PI) and Utilization Management (UM). • Experience with detailed medical record reviews. • Ability to apply clinical expertise for reviewing and validating vendor/provider decisions. • Skill in coaching and training other decision-makers on proper application of guidelines. • Expertise in peer review committees contributing to quality improvement teams. • Experience collaborating with providers through periodic case reviews for standardized decision-making. • Must be detail-oriented, thrive "in the weeds," and enjoy challenging medical record reviews. • Ability to ensure documentation supports services rendered aligns with guidelines of necessity. • Skill in investigating aberrant trends as part of cost containment initiatives. • Experience championing initiatives for reducing unnecessary hospital days, ER visits, and high-cost drug utilization.
Responsibilities
• By 90 Days: You have onboarded and familiarized yourself with company policies, workflows, and the specific PI/UM review processes. You've begun building rapport with the Medical Management team and key stakeholders. You are participating in case reviews with oversight, demonstrating your meticulous attention to detail and learning the technical tools. • By 6 Months: You are autonomously managing a significant volume of complex case reviews, making independent clinical decisions aligned with company guidelines and medical standards. You are identifying opportunities for process improvements in the PI and UM review process and are actively collaborating with the interdisciplinary team. • Ongoing: You are recognized as a subject-matter expert in Payment Integrity and medical necessity review, handling the most complex or high-stakes cases with high accuracy. You are playing a key role in shaping review strategies and guidelines and driving continuous improvement in our quality assurance processes. • Ongoing • You should get in touch if: • You are an MD or DO with a valid, unrestricted license to practice medicine in a US State. • You are Board Certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine. • You have at least 5 years of clinical experience, including inpatient experience. • You have strong experience in Payment Integrity and Utilization Management/Review and a solid understanding of Medicare Advantage. • You have experience or expertise with peer review committees. • You are extremely detail-oriented and meticulous, and you genuinely enjoy digging into medical records to find the "needle in the haystack". • You possess discerning clinical judgment and an investigative, problem-solving mindset. • You thrive in collaborative, cross-functional settings and have strong proficiency with technology.
Benefits
• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Remote-first culture, enabling collaboration with global teams • Paid parental leave for all new parents • We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare.
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