Medical Director, Utilization Management

About the role

Clover Health operates as a healthcare organization that combines data analytics with clinical expertise to serve its members. The Medical Director, Utilization Management holds a senior leadership position within the company's clinical operations division. This role is responsible for directing the review processes that determine whether healthcare services meet medical necessity standards and align with evidence-based clinical guidelines. The Medical Director oversees a team of clinicians and analysts who evaluate treatment plans, prior authorization requests, and care coordination decisions across the health plan's membership, ensuring that Clover Health delivers appropriate, high-quality care while managing costs effectively.

Key facts

What you'll do

Lead and manage the utilization management team responsible for reviewing clinical cases across the health plan's member population. Develop and maintain medical necessity criteria and coverage policies in alignment with evidence-based clinical guidelines and regulatory standards. Collaborate with physicians, nurses, and care management staff to evaluate complex cases and determine appropriate levels of care. Oversee the prior authorization process to ensure timely and accurate clinical decision-making for member treatments and procedures. Provide clinical expertise and guidance to internal teams on utilization trends, quality metrics, and member health outcomes. Represent the utilization management function in cross-functional meetings with product, operations, and compliance departments. Conduct regular audits of utilization review decisions to ensure consistency, fairness, and adherence to established protocols. Mentor and develop team members through performance reviews, training sessions, and career development planning. Analyze utilization data and reports to identify patterns, opportunities for improvement, and areas of clinical risk. Serve as a subject matter expert on regulatory requirements and industry standards related to utilization management and health plan operations.

Requirements

Medical degree from an accredited institution with active, unrestricted license to practice medicine in the United States. A minimum of ten years of clinical experience in a direct patient care setting, with preference for experience in managed care or health plan environments. At least three years in a leadership or supervisory role overseeing clinical teams and utilization review functions. Demonstrated knowledge of Medicare Advantage, Medicaid, and commercial health plan regulations and compliance standards. Strong understanding of medical necessity evaluation, prior authorization workflows, and utilization review methodologies. Excellent written and verbal communication skills with the ability to present clinical findings to diverse audiences. Proven ability to manage complex caseloads and make timely, well-reasoned clinical determinations. Experience working with electronic health record systems and data analytics platforms in a healthcare setting.

Nice to have

Board certification in a relevant medical specialty such as internal medicine, family medicine, or pediatrics. Familiarity with Clover Health's specific health plan products, care models, and member demographics. Prior experience leading quality improvement initiatives or clinical transformation projects within a health plan organization. Knowledge of value-based care models, population health management strategies, and alternative payment structures.

Skills & tools

Proficiency in utilization management software platforms and prior authorization systems used in health plan operations. Experience with data analysis tools and reporting dashboards to track clinical metrics and review outcomes. Familiarity with regulatory frameworks including Medicare Advantage rules, state insurance regulations, and HIPAA compliance requirements. Strong command of electronic health record systems such as Epic, Cerner, or equivalent platforms. Ability to interpret clinical data, claims information, and quality reports to inform utilization decisions. Competence in Microsoft Office Suite and collaboration tools for remote team coordination.

Practical notes

This role is performed entirely on a remote basis, with the expectation that the candidate maintains a dedicated home office setup suitable for clinical leadership work. The Medical Director is expected to be available during standard business hours and participate in regular virtual meetings with cross-functional teams across the United States. Occasional travel to Clover Health offices or industry conferences may be required as business needs dictate. The position involves handling sensitive member health information and requires strict adherence to all privacy and data security protocols.