Medical Director, Payment Integrity & Utilization Management

About Clover

Clover is reinventing health insurance by working to keep people healthier. We are a Medicare Advantage plan working to develop deeper insights to drive better outcomes for our members through our integrated technology platform. We rely on our abilities to integrate standard health plan data with clinical information from provider health information systems. The Medical Management team is at the center of this work, ensuring our members receive high-quality, appropriate care.

Role Overview

We are looking for an extremely detail-oriented Medical Director with a strong background in Payment Integrity (PI) and Utilization Management (UM). This is a full-time, hands-on role for someone who thrives "in the weeds" and enjoys the challenge of deep medical record review. You will be responsible for using your discerning clinical judgment to ensure medical necessity, appropriate utilization, and payment accuracy. This position reports to the Chief Medical Officer, Medicare Advantage (CMO).

Key Responsibilities

• Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines.
• Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided.
• Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines.
• Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives.
• Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends.
• Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization.
• Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making.

Success Milestones

• 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.

Qualifications

• 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 ensure accuracy.