Medical Director, Payment Integrity & Utilization Management
Clover Health(6 days ago)
About this role
Medical Director, Payment Integrity & Utilization Management at Clover focuses on ensuring medical necessity and payment accuracy for a Medicare Advantage plan through detailed clinical case and medical record review. The role supports cost-containment and quality improvement initiatives by collaborating with analytics, claims, providers, and peer review committees and reports to the CMO. This is a hands-on, full-time position in a remote-first environment.
Required Skills
- Record Review
- Payment Integrity
- Utilization Management
- Clinical Judgment
- Peer Review
- Cost Containment
- Data Analysis
- Provider Collaboration
- Coaching
- Technology Proficiency
Qualifications
- MD or DO
- Unrestricted Medical License
- Board Certified (Internal Medicine/Family Medicine/Emergency Medicine)
About Clover Health
cloverhealth.comClover Health is a Medicare Advantage provider offering HMO and PPO plans—many with $0 monthly premiums—bundling expanded benefits like dental, vision, and hearing. Headquartered in Jersey City, NJ, the company serves Medicare beneficiaries across multiple U.S. markets. Clover emphasizes a technology- and data-driven approach to care management, aiming to support providers, coordinate primary care, and improve member outcomes. It positions itself as a member-focused alternative designed to lower costs and simplify access to preventive and routine services.
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