Medical Director, Utilization Management (Home Health, Acute & Post-Acute)
Core
Physician leader for Utilization Management ensuring medically appropriate, evidence-based care and optimizing resource utilization across Home Health, acute, post-acute, outpatient, and pharmacy services.
Role type
Senior physician leader (Medical Director) for Utilization Management
Builds
Evidence-based medical necessity determinations and utilization management policies for Clover Health members
Domain
Healthcare insurance / Utilization Management / Home Health
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical necessity review, CMS regulations interpretation, Medicare coverage criteria application, peer-to-peer discussions, clinical guideline development, quality improvement initiatives, cross-functional collaboration, mentorship
Preferred skills
Medical Director experience, physician reviewer experience, acute/post-acute/outpatient/pharmacy review experience
Technologies
CMS Home Health regulations, Medicare Benefit Policy Manual, NCD/LCD, Milliman Care Guidelines, Clover clinical policies
Responsibilities
Review authorization requests for medical necessity across service lines, serve as primary physician reviewer for complex Home Health cases, conduct peer-to-peer discussions with providers, mentor Utilization Management nurses, participate in reviewer calibration sessions, support development of clinical guidelines and policies, collaborate with Home Health agency partners
Seniority
Senior, hands-on IC with leadership responsibilities