• Support Headway health plan partnerships and strategy • Promote external relations with Payers through relationship building, presentations/reporting, sales meetings, and conference participation • Drive creative, innovative, exploratory data analyses to prove patient outcomes, generate novel insights, shape strategic direction, and demonstrate scientific and strategic value to customers • Develop a critical understanding of how mental health clinicians utilize digital tools to deliver high quality care and document in a compliant manner • Work collaboratively with cross functional teams including product, design, growth, marketing, payer relations, data & analytics, and operations • Be willing to travel.

• 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.

• The Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. • The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health’s medical policies reviews to determine medical necessity or if an alternate treatment plan is required for our members. • Successfully completes all required new hire training modules and certifications • Demonstrates a foundational understanding of Clover Health's medical policies, guidelines, and utilization management processes • Begins to independently review cases with increasing efficiency and accuracy, requiring minimal oversight • Establishes positive working relationships with team members and key stakeholders • Consistently meets or exceeds productivity targets for case reviews and determinations • Maintains a high level of accuracy in medical necessity determinations and documentation • Actively participates in team meetings and contributes to process improvement discussions • Demonstrates a comprehensive understanding of complex medical cases and escalates issues appropriately.

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.