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December 09, 2019  
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Contract Behavioral Health Medical Director, Utilization Management - Remote Part-time

Position Description

insurance by working to keep people healthier.

We value diversity in backgrounds and experiences. Healthcare is a

universal concern, and we need people from all backgrounds and swaths of life

to help build the future of healthcare.

Clover's UM team works to build & refine complex, highly-regulated processes in

order to improve the health outcomes of our members.The Behavioral Health

Medical Director provides operational leadership and is responsible for

ensuring the clinical accuracy of all reconsiderations and payment disputes and

reviewing and refining all IRE case narratives. This position is remote and

part-time (approximately 10 hours a week).


* Perform individual case review for psychiatric admissions. Communicate

with medical directors regarding appeals decision rationales, and benefit


* Actively participate in team meetings focused on communication, feedback,

problem solving, process improvement, staff training and evaluation, and

the sharing of program results.

* Utilize MCG Criteria, CMS Guidelines, medical and administrative policies

to evaluate medical necessity of requested service, applying sound

clinical judgement.



* You are empatheticand have excellent telephonic and interpersonal

communication skills.

* You thrive in a collaborative environment, working together being a part

of a team and have strong team building skills.

* You areservice oriented you feel fulfilled in helping and supportin

others to achieve common goals while resolving issues while seeing

opportunities to problem solve creatively.

* You have an insatiable curiosity and appetite to learn the mechanics of

complex systems - healthcare is especially intricate and highly


* You are a self-starterwho learns new tools quickly and has a keen eye to

improve things.

* You believe fiercely in the protection of our members.

* You understand thatcompliance is not just a set of rules you follow, it's

the way you work.



* You are an MD or DO with an active, unrestricted license.

* You have 5+ years Psychiatric clinical practice experience.

* You have 2+ years of working experience in a managed care organization.

* You have a minimum of 2+ years Medicare Advantage appeals experience.

* You have experience with CMS guidelines, regulations, and audits.

* You have Microsoft office or Mac computer skills including experience

with typing, word processing, presentations, spreadsheet experience and

Internet researching skills.


Pursuant to the San Francisco Fair Chance Ordinance, we will consider for

employment qualified applicants with arrest and conviction records. We are anE-


About Clover:We are reinventing health insurance by combining the power of data

with human empathy to keep our members healthier. We believe the healthcare

system is broken, so we've created custom software and analytics to empower our

clinical staff to intervene and provide personalized care to the people who

need it most.

We always put our members first, and our success as a team is measured by the

quality of life of the people we serve. Those who work at Clover are passionate

and mission-driven individuals with diverse areas of expertise, working

together to solve the most complicated problem in the world: healthcare.

From Clover s inception, Diversity & Inclusion have always been key to our

success. We are an Equal Opportunity Employer and our employees are people with

different strengths, experiences and backgrounds, who share a passion for

improving people's lives. Diversity not only includes race and gender identity,

but also age, disability status, veteran status, sexual orientation, religion

and many other parts of one s identity. All of our employee s points o

view are key to our success, and inclusion is everyone's responsibility.

Clover Health welcomes qualified candidates with disabilities and will provide

accommodations during the interview process as needed. If you require

accommodations, please email *************************** with the details of

your requested accommodation. Requests are reviewed by a member of the

recruiting team. Requests will have no bearing on the candidate evaluation

process or hiring decisions.

Additional Information

Employment Type: Full-Time    
Position Location: Nashville, Tennessee

Apply For This Job: Contract Behavioral Health Medical Director, Utilization Management - Remote Part-time


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