RemoteLeaf Logo
Log in Sign up

Medical Director, Payment Integrity & Utilization Management

1 hour, 42 minutes ago
United States
Full-time
Senior
Business Analyst
Data Science and Analytics
Apply Now
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised
View All Jobs 27

Description

  • Perform detailed medical record reviews to confirm documentation supports services rendered and aligns with medical necessity guidelines.
  • Apply clinical expertise to review and validate vendor and provider clinical decision-making and reimbursement determinations.
  • Coach and train other clinical decision-makers on proper selection and application of medical necessity guidelines.
  • Participate in peer review committees and contribute to quality improvement initiatives.
  • Serve as a clinical leader for cost containment efforts with data analytics, claims, and FWA teams.
  • Investigate aberrant trends and support actions to reduce unnecessary hospital days, avoidable ER visits, and inappropriate high-cost drug utilization.
  • Collaborate with providers through periodic case reviews to promote consistent and standardized decision-making.
  • Handle complex and high-stakes cases with strong clinical judgment and attention to detail.
  • Help shape review strategies, guidelines, and continuous improvement efforts in quality assurance processes.

Requirements

  • MD or DO with a valid, unrestricted license to practice medicine in a U.S. state.
  • Board certified, preferably in Internal Medicine, Family Medicine, or Emergency Medicine.
  • At least 5 years of clinical experience, including inpatient experience.
  • Strong experience in Payment Integrity and Utilization Management/Review.
  • Solid understanding of Medicare Advantage.
  • Experience or expertise with peer review committees.
  • Extremely detail-oriented and meticulous, with comfort reviewing medical records in depth.
  • Discerning clinical judgment and an investigative, problem-solving mindset.
  • Ability to thrive in collaborative, cross-functional settings.
  • Strong proficiency with technology.
  • Experience in or familiarity with quality improvement and review processes (preferred).

Benefits

  • Competitive base salary of $270,000 to $330,000.
  • Equity opportunities, including Employee Stock Purchase Plan (ESPP).
  • Performance-based bonus program.
  • 401(k) matching and regular compensation reviews.
  • Comprehensive medical, dental, and vision coverage.
  • Remote-first work culture.
  • Generous flexible time-off policy, plus No-Meeting Fridays and monthly company holidays.
  • Access to mental health resources.
  • Learning programs, mentorship, and professional development funding.
  • Paid parental leave for all new parents.
  • Reimbursement for office setup expenses.
  • Monthly cell phone and internet stipend.

Interested in this position?

Apply directly on the company website

Apply Now

Similar Roles

Stress-Free Auto Care

General Manager

Stress-Free Auto Care 11-50 Automotive

Stress Free Auto Care is seeking a General Manager to lead the daily operations of a high-volume auto service location, with full accountability for profitability, team performance, operational execution, and customer experience as the company scales rapidly.

United States Full-time Lead Operations Manager
$100k-$120k
12 minutes ago
GR8 Tech

Head of Turnkey Solution

GR8 Tech 251-1K IT Services

GR8 Tech is hiring a Head of Turnkey Platform to lead its B2B iGaming all-in-one platform business, owning strategy, operations, and commercial performance for operators.

Anywhere Full-time Lead Operations Manager Product Manager
CRM
12 minutes ago
Relativity Space

Staff Global Supply Manager, Vehicle Structures

Relativity Space 251-1K Aerospace & Defense

Relativity Space is hiring a Global Supply Manager, Vehicle Structures to build and scale supply chains for the Terran R rocket program, supporting the sourcing, delivery, and manufacturability of complex vehicle structures.

United States Full-time Lead Operations Manager
$141k-$194k
Assembly ERP Oracle SAP
12 minutes ago
Alphasense

Operations Manager, Channel and Customer Research

Alphasense 51-250 Industrial Conglomerates

AlphaSense is hiring an Operations Manager for its Channel & Customer Research team to lead research pods that deliver high-quality primary research and actionable market insights for enterprise and institutional clients.

United Kingdom Full-time Lead Operations Manager
27 minutes ago

You're on a roll! Sign up now to keep applying.

Sign Up

Already have an account? Log in

Used by 14,729+ remote workers