Medical Director, Utilization Management (UM) & Quality Assurance (QA)

Clover is reinventing health insurance by working to keep people healthier.

Clover is 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 (eligibility, provider network, claims, authorizations, etc.) with clinical information from provider health information systems.

This is a full time position that participates in and is responsible for certain quality measurement, control and improvement activities that take place in the Medical Management area (i.e. UM and Appeals). The position reports to the Chief Medical Officer, Medicare Advantage (CMO).

As a Medical Director, you will:

• Review ongoing sample cases of medical decision-making by vendors and delegated providers.
• Support QA team in evaluating and improving UM and Appeal processes.
• Coach and train clinical decision makers to improve proper selection and application of medical  necessity  guidelines.
• Perform in-depth trend data analysis and develop quarterly performance reports.
• Support the Senior Medical Director by preparing reports for the Medical Management Committee, MMC, and Quality Improvement Committee.
• Identify and develop opportunities for innovation to increase service and clinical quality.
• Lead or contribute to quality improvement committees and teams.
• Serve on quality improvement teams as a leader, participant or consultant.
• Participate in company efforts to improve quality metrics such as STARS and HEDIS measures; member and provider satisfaction.
• Execute additional QA responsibilities as assigned by the CMO.
• Maintain credentials as required for employment with Clover Health.
• Collaborate with providers to ensure consistent and standardized decision-making through periodic case reviews.

Success in this role looks like:

Leadership & Strategy: Play a leadership role in shaping clinical review strategies, guidelines, and processes. Collaborate with other medical directors and senior leadership to set long-term goals.

Advanced Decision-Making: Take on more complex or high-stakes case reviews, ensuring thorough decision-making with high accuracy and compliance with regulatory requirements.

Quality Assurance: Establish or refine quality assurance processes for clinical reviews, ensuring that reviews meet or exceed industry standards.

Continuous Improvement: Drive innovation in clinical review practices, including the implementation of new technologies or methodologies. Ensure the ongoing development of team members and systems to keep pace with healthcare changes.

You should get in touch if:

• You are an 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 specialty, preferred.
• You have clinical experience of at least 5 years with inpatient experience.
• You have Utilization management/review experience.
• You have Medicare Advantage experience.
• You thrive in collaborative, cross-functional settings.
• You have proficiency with computers/technology.

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