Lead Medical Director, Utilization Management

Clover Health

. Evaluate all outpatient referrals and inpatient direct admissions for medical appropriateness .

Posted 11/5/2026full-timeRemote • United StatesSenior💰 $320,000 - $340,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management, including clinical policy development, medical necessity criteria, and team leadership. Possesses strong clinical judgment and communication skills to effectively manage complex cases and contribute to quality improvement initiatives.

Highest-signal resume keywords

MD Or DO DegreeActive Medical LicenseBoard Certification In Relevant Clinical Specialty5 Years Clinical Practice Experience In Utilization Management5 Years Leadership Experience Managing Clinical Team

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementMedical Necessity ReviewClinical Policy DevelopmentEvidence-Based GuidelinesQuality ImprovementRegulatory ComplianceClinical DocumentationData AnalysisCase ReviewPolicy Recommendations

Soft Skills

Clear CommunicationConflict ResolutionClinical JudgmentTeam CollaborationCommittee Contribution

Industry Keywords

Utilization Management CommitteeCredentialing CommitteeQuality CommitteeClinical IntegrityAccreditation Readiness

About the role

Key responsibilities & impact

Evaluate all outpatient referrals and inpatient direct admissions for medical appropriateness
Complete assigned prior authorization, concurrent, retrospective, and other utilization management cases within established turnaround expectations
Ensure clinical decisions align with applicable medical necessity criteria and support clinical integrity of UM reviews
Manage a team of Utilization Management Medical Directors
Review complex or escalated cases and obtain specialty consultation when needed
Develop, review, and maintain clinical policies, pharmacy policies, medical necessity criteria, and UM procedures
Monitor emerging evidence and recommend policy updates
Chair the Utilization Management Committee, including agendas, policy recommendations, utilization trends, decisions, and follow-through
Serve on the Credentialing Committee and provide physician input on credentialing matters, provider qualifications, and clinical concerns
Contribute to the Quality Committee by identifying trends and recommending improvements
Participate in peer-to-peer discussions, appeals, and provider education
Use audits, case reviews, appeals, complaints, and UM performance data to improve policies, clinical practice, and workflows
Partner with care management, quality, compliance, network, pharmacy, and operations teams
Support regulatory and accreditation readiness through clinical documentation, committee records, and corrective actions
Advise organizational leaders on UM strategy, clinical risks, and member and provider experience
Learn UM policies, workflows, committee processes, and documentation expectations during the first 90 days
Complete reviews consistently, contribute to committee work, and identify case or policy trends within the first 6 months
Support clear policies, consistent clinical decisions, committee follow-through, and measurable improvements in quality, access, or outcomes over time

Requirements

What you’ll need

MD or DO degree and an active, unrestricted medical license
Board certified in a relevant clinical specialty
At least 5 years of clinical practice experience in utilization management or medical necessity review
At least 5 years of leadership experience directly managing a clinical team
Understanding of evidence-based guidelines, coverage policy, quality improvement, and applicable regulatory and accreditation requirements
Strong clinical judgment, clear communication, sound conflict resolution, and ability to contribute effectively in committees

Benefits

Comp & perks

Competitive base salary
Equity opportunities
Performance-based bonus program
401k matching
Regular compensation reviews
Comprehensive medical, dental, and vision coverage
No-Meeting Fridays
Monthly company holidays
Mental health resources
Generous flexible time-off policy
Remote-first culture supporting collaboration and flexibility
Learning programs
Mentorship
Professional development funding
Regular performance feedback and reviews
Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
Reimbursement for office setup expenses
Monthly cell phone & internet stipend
Paid parental leave for all new parents