We’re looking to hire a Utilization Management Medical Director to support our growing operations. This role will be a full-time position (40 hours weekly) responsible for the evaluation of all outpatient referrals for Part B Step Therapy Reviews as well as some inpatient reviews for medical appropriateness. The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health’s medical policies reviews, and Step Therapy Guidance to determine medical necessity or if an alternate treatment plan is required for our members. Clover Health’s Medical Management Committee provides oversight of the utilization review process and ensures that all decisions comply with accepted standards for determination of medical necessity.
As a Utilization Management Medical Director, you will:
Participate and support the Clover Health Utilization Management processes.
Evaluate outpatient referral requests and...