Medical Director, Utilization Management (Home Health, Acute & Post-Acute)

Clover’s Utilization Management (UM) team brings together experienced physicians and clinicians to ensure members receive medically appropriate, evidence-based care while optimizing quality and resource use.

About the role

As the Medical Director, Utilization Management, you will support timely utilization decisions across the care continuum, with a primary focus on Home Health services. You will also review acute, post-acute, outpatient, and pharmacy authorization requests. In this role, you will serve as the physician leader for Home Health utilization management, reviewing complex authorization requests for episodic and per-visit services to determine medical necessity. You will apply CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines, and Clover Health clinical policies to ensure consistent, evidence-based decision-making that supports high-quality member care.

You will partner closely with the Home Health RN Lead, Utilization Management nurses, providers, and cross-functional teams to improve clinical outcomes, promote appropriate utilization, and advance Clover’s commitment to delivering exceptional Home Health services.

Responsibilities

• Participate in and support Clover Health Utilization Management processes.
• Review authorization requests for Home Health, acute inpatient, post-acute, outpatient, and pharmacy services for medical necessity.
• Serve as the primary physician reviewer for complex Home Health authorization requests requiring Medical Director determination.
• Review both episodic and per-visit Home Health authorization requests using CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), and Clover clinical guidelines.
• Evaluate acute inpatient admissions, post-acute services, skilled nursing facility, inpatient rehabilitation, long-term acute care, outpatient, and pharmacy requests within established turnaround times.
• Apply evidence-based medical necessity criteria while promoting appropriate utilization across all service lines.
• Serve as the physician escalation point for complex Home Health medical necessity determinations submitted by the Utilization Management nursing team.
• Perform peer-to-peer discussions with physicians, Home Health agencies, hospitals, and other providers to facilitate appropriate care decisions.
• Partner with the Home Health RN Lead to ensure consistent interpretation and application of Home Health coverage criteria.
• Mentor and educate Utilization Management nurses on complex Home Health cases, including episodic and per-visit review methodologies.
• Participate in Home Health reviewer calibration sessions, quality initiatives, and ongoing education to improve consistency and decision quality.
• Support the ongoing development of Clover Health clinical guidelines, utilization management policies, and Home Health review criteria.
• Collaborate with Home Health agency partners to promote evidence-based care, improve documentation quality, and support optimal member outcomes.
• Support quality improvement initiatives for Clover members.

Success in this role

• Within your first 90 days, you will:
  • Become fully proficient in Clover’s Utilization Management workflows, Home Health review processes, CMS regulations, and Medicare coverage criteria through successful onboarding and training.
  • Independently review Home Health, acute, post-acute, outpatient, and pharmacy authorization requests while consistently meeting quality, productivity, and turnaround time expectations.
  • Build strong partnerships with the Home Health RN Lead, Utilization Management nurses, providers, and cross-functional teams while serving as a trusted clinical resource for complex cases.
• Within your first 6 months, you will:
  • Be recognized as a subject matter expert in Home Health utilization management, providing consistent, evidence-based medical necessity determinations across all service lines.
  • Lead effective peer-to-peer discussions and contribute to reviewer education, calibration sessions, and quality improvement initiatives that strengthen clinical consistency.
  • Partner with clinical and operational leaders to enhance reviewer quality, improve utilization management performance, and support positive member outcomes.
• As you continue to grow in the role, you will:
  • Drive continuous improvement of Clover’s Home Health utilization management program through clinical leadership and evidence-based decision-making.
  • Influence the development of utilization management policies, clinical guidelines, and best practices that improve quality, consistency, and operational excellence.
  • Serve as a trusted physician leader who collaborates across teams to optimize member outcomes, provider partnerships, and resource utilization.

Requirements

• MD or DO degree, board certified in a relevant specialty, and hold an unrestricted U.S. medical license.
• 5+ years of clinical experience, including Utilization Management and Medicare Advantage experience.
• Expertise reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria; experience serving as a Medical Director or physician reviewer is preferred.
• Experience reviewing acute, post-acute, outpatient, and/or pharmacy services.
• Ability to collaborate across interdisciplinary teams to deliver high-quality, evidence-based care.
• Effective communicator who thrives in peer-to-peer discussions, values relationship building, and is passionate about improving member outcomes through innovation and technology.

Benefits

• Financial Well-Being: Competitive base salary and equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and vision coverage for employees and their families.
• Mental Well-Being: No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Remote-first culture supporting collaboration and flexibility.
• Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Additional Perks:
  • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities.
  • Reimbursement for office setup expenses.
  • Monthly cell phone & internet stipend.
  • Remote-first culture, enabling collaboration with global teams.
  • Paid parental leave for all new parents.
  • And much more!

Pay

A reasonable estimate of the base salary range for this role is $242,300—$315,000 USD.