Job Closed

This listing is no longer active.

Clover Health logo
Clover Health

Clover is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans.

Medical Director, Payment Integrity – Utilization Management

Medical DirectorMedical DirectorOtherRemoteLeadTeam 501-1,000H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

144 days ago

Salary

$270K - $330K / year

Seniority

Lead

Postgraduate Degree5 yrs expEnglish

Job Description

Medical Director, Payment Integrity – Utilization Management

Clover Health

• Perform detailed, medical record reviews (e.g., 30-day readmissions) to ensure documentation supports the services rendered and aligns with medical necessity guidelines. • Apply your clinical expertise to review and validate clinical decision-making by vendors and providers to ensure proper reimbursement for services provided. • Coach and train other clinical decision-makers, helping them improve the proper selection and application of medical necessity guidelines. • Leverage your expertise in peer review committees to support and contribute to quality improvement teams and initiatives. • Serve as the key clinical leader for cost containment initiatives, collaborating with data analytics, claims, and FWA departments to investigate and act on aberrant trends. • Champion initiatives to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization. • Collaborate with providers through periodic case reviews to ensure consistent and standardized decision-making. • Please note: This role is focused on clinical case review and does not require after-hour calls, holidays, or weekends.

Job Requirements

  • You are an MD or DO with a valid, unrestricted license to practice medicine in a US State.
  • You are Board Certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine.
  • You have at least 5 years of clinical experience, including inpatient experience.
  • You have strong experience in Payment Integrity and Utilization Management/Review and a solid understanding of Medicare Advantage.
  • You have experience or expertise with peer review committees.
  • You are extremely detail-oriented and meticulous, and you genuinely enjoy digging into medical records to find the "needle in the haystack".
  • You possess discerning clinical judgment and an investigative, problem-solving mindset.
  • You thrive in collaborative, cross-functional settings and have strong proficiency with technology.

Benefits

  • Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
  • Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
  • Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
  • Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
  • 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!

Related Categories

Related Job Pages

More Medical Director Jobs

Affect Therapeutics logo

Family Nurse Practitioner

Affect Therapeutics

Digital treatment for alcohol & drug addiction delivered through a revolutionary smartphone app that motivates recovery

Medical Director144 days ago
OtherRemoteTeam 11-50H1B No Sponsor

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Affect is transforming behavioral health care by combining mobile technology with counseling and medical services, offering 100% virtual treatment. We break down barriers to care, making it more accessible and effective for our members. Our innovative approach integrates a smartphone app with a dedicated care team to deliver real-time, data-driven treatment for better outcomes and lower costs. As a FNP, you will lead member care alongside a team of counselors, therapists, peer support specialists, and case managers. You’ll provide evidence-based treatment for individuals with substance use disorders. We do not prescribe controlled substances other than Suboxone for the treatment of Opioid Use Disorder. Affect provides extensive training on evidence-based approaches to treatment, though medication decisions are ultimately made at the provider’s discretion in collaboration with the member. You must hold an active, unrestricted license in Indiana. Key Responsibilities - Conduct initial and follow up telehealth evaluations - Deliver care for substance use - Prescribe medications as appropriate and answer member questions - Complete documentation in our EHR (Healthie) - Collaborate with your care team and attend occasional scheduled team meetings Qualifications - Active and verifiable FNP license (Medicaid enrollment is a plus) in the state(s) where you practice, as well as your state of residence if it is not Indiana - At least 2 years of experience, ideally in addiction. We will consider relevant previous experience for those with less than 2 years experience as a FNP - Experience prescribing Suboxone and active DEA registration - Willingness to obtain multi-state licensure (cost covered by Affect) - Empathy for members facing behavioral health challenges - Comfort using technology, including EHRs and mobile apps Additional Information You’ll need a quiet, private office with a reliable internet connection for HIPAA-compliant telehealth visits. The role may include periodic meetings with internal teams; reasonable accommodations are available as needed. Benefits - Competitive compensation - Remote flexibility - Professional growth - A strong, supportive culture Company Description We are passionate about reimagining behavioral health treatment. Join a mission-driven team focused on meaningful work.

United States
Job Closed
Caris Life Sciences logo

Senior Medical Director – GI/GU

Caris Life Sciences

Fulfilling the promise of precision medicine through quality and innovation.

Medical Director144 days ago
OtherRemoteTeam 1,001-5,000Since 2008H1B No Sponsor

• Serve as the senior clinical and scientific voice for Caris in GI/GU oncology, representing the company at national and international meetings, academic institutions, and major cancer centers. • Deliver high-impact public and scientific presentations to clinicians, researchers, and thought leaders, translating complex genomic science into clear, clinically relevant insights. • Cultivate and maintain strategic relationships with key opinion leaders (KOLs), clinical collaborators, and POA member institutions to advance the Caris mission and strengthen brand leadership in precision oncology. • Partner with internal stakeholders across R&D, Medical Affairs, Commercial, Business Development, and Marketing to ensure clinical accuracy, alignment, and innovation in messaging and product positioning. • Advise on clinical strategy and evidence generation to support Caris’ growing presence in GI/GU oncology, including input on prospective trials, retrospective analyses, and real-world data initiatives. • Contribute thought leadership to Caris’ scientific communications—advisory boards, symposia, webinars, publications, and slide decks that convey Caris’ scientific differentiation. • Provide clinical mentorship to field-based medical personnel (e.g., Medical Science Liaisons), enhancing their effectiveness in customer engagement and scientific storytelling. • Collaborate on content development for GI/GU oncology education programs, internal trainings, and professional/continuing medical education (CME) initiatives. • Bridge insights from the field to internal teams, ensuring the evolving needs of GI/GU oncologists and researchers inform product innovation and R&D priorities.

United States
$320K - $360K / year
Full TimeRemoteTeam 10,001+Since 2018H1B Sponsor

• Develop and execute system-wide strategies for pathology services aligned with laboratory and organizational priorities. • Oversee market pathology groups’ alignment to ministry goals to assure efficiency, consistency, and service excellence. • Develop and, wherever possible, standardize pathology productivity and performance metrics across the ministry. • Provide guidance to market medical directors in the development of quality assurance programs, including proficiency testing, peer review, and internal audits. • Remain abreast of evolving best practices, technologies, and regulatory requirements in pathology and laboratory medicine. • Foster transparency and collaboration among pathology groups across markets by instilling a culture of continuous improvement in pathology services. • Chair the Clinical & Scientific Board, Lab Regulatory Oversight Committee, Lab Stewardship Committee, Patient Blood Management Committee, and other enterprise-wide committees, projects, and initiatives, as assigned. • Ensure site medical directors are compliant with all federal, state, and local regulations and are in good standing with market medical operations. • Provide feedback to executive leadership team and market leadership in the performance and evaluation of site medical directors. • Participate in strategic discussions in the buy vs sell analysis of test internalization and in the evaluation of new equipment. • Participate with the executive leadership team in driving cost-effective service delivery with focus on improving quality. • Serve as a key liaison between pathology, clinical departments, hospital leadership, and external partners.

United States
Trinity Health logo

Chief Medical Officer, CMO – PACE

Trinity Health

We are one of the largest not-for-profit, faith-based health care systems in the nation.

Medical Director144 days ago
OtherRemoteTeam 10,001+H1B Sponsor

• Provide clinical leadership and oversight of all owned PACE programs • Collaborate with a variety of system-level leaders in the departments of Finance, Quality, Compliance, Informatics, Coding, Claims adjudication, Education, Credentialing and Operations • Create and maintain an atmosphere of warmth, propagating a calm environment throughout the office • Promote and maintain collaborative relationships with managers, peers, direct reports and customers • Coordinate communication with Pharmacy Benefit Manager and pharmacy provider(s) as necessary • Participate in Part D audits and development of corrective action plans • Establish expectations for Utilization Management meetings

United States
Job Closed