Medical Director, Payment Integrity & Utilization Management

Cloverhealth

Remote
Base: $270,000 to $330,000; bonus/equity: performa...
Remote
Medical record review
Clinical judgment
Payment accuracy
Clover Health is seeking a detail-oriented Medical Director specializing in Payment Integrity and Utilization Management for a remote position. The ideal candidate will have a strong clinical background, particularly in Medicare Advantage, and a passion for improving healthcare outcomes through meticulous medical record review

Job Summary

  • Perform detailed medical record reviews to ensure documentation supports services rendered and aligns with medical necessity guidelines.
  • 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.
  • We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier.

Matching Summary

Match Score: 85

Clover Health is seeking a detail-oriented Medical Director specializing in Payment Integrity and Utilization Management for a remote position. The ideal candidate will have a strong clinical background, particularly in Medicare Advantage, and a passion for improving healthcare outcomes through meticulous medical record review.

Salary

Base: $270,000 to $330,000; Bonus/Equity: Performance-based bonus program, equity opportunities; Benefits: Comprehensive medical, dental, and vision coverage, 401k matching, flexible time-off

Skills & Requirements

Must-have

  • Medical record review
  • Clinical judgment
  • Payment accuracy
  • Cost containment initiatives
  • Provider collaboration

Nice-to-have

  • Deep medical record review
  • Investigative problem-solving mindset
  • Collaborative cross-functional settings

Key Requirements

  • MD or DO with valid, unrestricted license
  • Board Certified in Internal Medicine, Family Medicine, or Emergency Medicine
  • 5+ years clinical experience
  • Inpatient experience
  • Strong Payment Integrity and Utilization Management/Review experience
  • Solid understanding of Medicare Advantage
  • Experience with peer review committees

Work Rights

Not specified

Tailored Resume

Cover Letter