Associate Chief Medical Officer, Medicare Advantage

At Clover Health we are committed to providing high-quality affordable and easy-to-understand healthcare plans for Americas seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each members complete health history we ensure better care at a lower costdelivering the highest value to those who need it most.

We are seeking a visionary executive leader to join us as our Associate Chief Medical Officer (ACMO) to own and elevate the strategy and operations of our Utilization Management function. This pivotal role will provide strategic and clinical leadership for the entire Utilization Management (UM) function across Clovers Medicare Advantage (MA) program. You will be responsible for defining the vision setting the standards and ensuring the clinical quality and compliance of all UM programs significantly impacting our ability to drive down costs while delivering superior patient-centered care for our members. You will lead and mentor a team of physician leaders and UM nurses to optimize decision-making and ensure medical necessity determinations are consistent timely and aligned with our mission.

As an Associate Chief Medical Officer Medicare Advantage you will:

• Define and direct the strategic roadmap for all Utilization Management activities ensuring clinical excellence regulatory compliance and alignment with Clover Healths overall commitment to member health outcomes.
  
  
• Provide executive oversight and mentorship to the Utilization Management team including Medical Directors and UM nurses fostering their clinical development and strengthening the effectiveness of the entire UM function.
  
  
• Spearhead the ongoing development and implementation of Clover Healths clinical guidelines ensuring they incorporate current national standards (such as Milliman Care Guidelines Interqual Criteria and CMS Determinations) to consistently facilitate high-quality medically appropriate care.
  
  
• Act as a senior clinical liaison engaging in high-level peer-to-peer discussions with network primary care physicians and specialists to resolve complex service requests and ensure seamless continuity of care for our members.
  
  
• Lead operational excellence by evaluating utilization trends developing educational resources for providers and streamlining the UM Grievance and Appeals processes to reduce friction and improve transparency for physicians.
  
  
• Drive quality improvement initiatives by partnering closely with Clover Healths Medical Management Committee to review the utilization process and ensure all decisions adhere to accepted standards for medical necessity.

Success in this role looks like:

• Within the first 90 days: Youve completed a comprehensive assessment of the current UM infrastructure established clear performance metrics and development plans for your direct reports and actively supported the Medical Management Committee in reviewing and refining key utilization review processes.
  
  
• Within the first 6 months:You have successfully implemented at least one major strategic initiative to improve the efficiency and quality of medical necessity determinations resulting in measurable improvements in case timeliness and consistency and youve significantly contributed to the ongoing evolution of Clovers clinical guidelines.
  
  
• In the Future: The UM function operates as a high-performing clinically sound and compliant program evidenced by sustained positive utilization trends exceptional outcomes in quality and cost of care and your success in developing and retaining a high-caliber team of physician and nurse leaders.

You should get in touch if:

• You are a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) with an active unrestricted medical license in a US State and are board-certified in Internal Medicine Family Medicine or a related primary care specialty.
• You have at least 5 years of demonstrated executive leadership experience (ACMO CMO or equivalent role) in a managed care Medicare Advantage or similar complex healthcare environment.
• You possess extensive experience in Utilization Management/Review and have a proven track record of providing strategic leadership and clinical direction over a complex UM program in a Medicare Advantage or Managed Care setting.
• You have demonstrated executive leadership ability in mentoring and coaching other physicians and clinical staff with the ability to clearly communicate a clinical vision to diverse stakeholders and foster a collaborative team environment.
• You are excited by complicated industry-wide problems and possess a natural intellectual curiosity that drives you to find and implement creative yet simple technology-enabled solutions to improve patient care.
• You have a deep understanding of and experience applying national standards for medical necessity such as Milliman Care Guidelines Interqual Criteria and CMS Coverage Determinations.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally we offer a performance-based bonus program 401k matching and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical dental and vision coverage. Your health matters to us and we invest in ensuring you have access to quality healthcare.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this we offer initiatives such as No-Meeting Fridays monthly company holidays access to mental health resources and a generous flexible time-off policy. Additionally we embrace a remote-first culture that supports collaboration and flexibility allowing our team members to thrive from any location.
• Professional Development: Developing internal talent is a priority for Clover. We offer learning programs mentorship professional development funding and regular performance feedback and reviews.

Additional Perks:

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture enabling collaboration with global teams
• Paid parental leave for all new parents
• And much more!

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 weve 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 Clovers 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 perspectives opinions and backgrounds who share a passion for improving peoples lives. Diversity not only includes race and gender identity but also age disability status veteran status sexual orientation religion and many other parts of ones identity. All of our employees points of view are key to our success and inclusion is everyones responsibility.

#LI-REMOTE

Pursuant to the San Francisco Fair Chance Ordinance we will consider for employment qualified applicants with arrest and conviction records. We are anE-Verifycompany.

A reasonable estimate of the base salary range for this role is $321000 - $392000. Final pay is based on several factors including but not limited to internal equity market data and the applicants education work experience certifications etc.