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

About this role

The Utilization Management (UM) team is made up of experienced physicians and clinicians who work together to ensure Clover members receive medically appropriate, evidence-based care while optimizing quality and resource utilization. As the Medical Director, Utilization Management, you will play a critical role in supporting timely utilization decisions across the continuum of care, with a primary focus on Home Health services while also reviewing 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. Leveraging CMS Home Health regulations, the Medicare Benefit Policy Manual, National and Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines, and Clover Health clinical policies, you will help ensure consistent, evidence-based decision-making that supports high-quality member care.

You'll 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. As a Medical Director, Utilization Management, you will: 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.