Evaluate outpatient referrals and inpatient admissions for medical appropriateness.
Perform peer-to-peer discussions with providers and support utilization management processes.
Mentor UM nurses and contribute to clinical guideline development.
Clover Health is reinventing health insurance by combining data with human empathy to keep members healthier. It is a mission-driven company focused on providing high-quality, affordable healthcare for America's seniors.
Lead, coach, and onboard Utilization Management nurses while managing daily workloads and escalations.
Ensure reviews and determinations are timely, accurate, and compliant with CMS and Clover policies.
Collaborate with Medical Directors and cross-functional teams to improve workflows and member outcomes.
Clover Health provides data-driven healthcare plans for seniors, using the Clover Assistant to support physician decisions. The company is a mission-driven team of diverse experts focused on improving members' quality of life.
Lead UM decisions, clinical oversight, and complex case reviews for medical necessity.
Conduct peer-to-peer payer reviews to support authorizations and overturn denials.
Educate providers on documentation, identify gaps, and support audit response.
Council Capital is a healthcare-focused private equity firm based in Nashville, TN, managing over $350M in committed capital. We invest in lower middle market healthcare companies and support founders through our Council Model of operators, investors, and value creation experts.
Leads and develops a team of Medical Directors and Clinical Directors driving clinical strategy across enterprise value-based care contracts.
Owns clinical performance outcomes, resource deployment, and strategic market relationships.
Recruits and mentors clinical leaders while representing the clinical voice in company-wide strategy.
Aledade PBC is a public benefit corporation that empowers independent primary care practices by building value-based care contracts and technology. Founded in 2014, it is the largest network of independent primary care in the U.S. and fosters a collaborative, inclusive, remote-first culture.
Perform clinical reviews to evaluate medical necessity, level of care, and benefit coverage for members.
Apply internal policies, MCG, and NCCN guidelines to deliver timely and compliant utilization management decisions.
Escalate complex cases and build audit-ready documentation for Medical Director review.
Personify Health created the first and only personalized health platform, bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. Their mission-driven culture empowers diverse perspectives to drive real impact on people's health.
Own clinical outcomes for Mira patients, including readmissions, ER visits, and falls.
Build and ship root-cause geriatric programs using the 5Ms.
Set clinical standards for product and AI workflows and align with operations, billing, payers, and regulators.
Mira Mace is a venture-backed company helping Medicare patients navigate a complex healthcare system with clarity and confidence. It pairs people-centered navigation with technology and emphasizes autonomy, speed, and accountability.
Own the CCV workforce plan end to end, translating long-range growth targets into weekly and monthly hiring, onboarding, and readiness goals.
Build a scalable clinician onboarding model and leadership capacity to support rapid growth without sacrificing clinical quality.
Turn workforce data into decisions through dashboards, forecasts, and operating rhythms that manage performance and capacity.
Clover Health is reinventing health insurance by combining the power of data with human empathy to keep members healthier. They are a mission-driven, remote-first company with diverse expertise, focused on improving healthcare.
Lead clinical strategy and own outcome metrics for Medicare patients, including hospital readmissions and ER utilization.
Design scalable geriatric intervention programs using the 5Ms framework to prevent avoidable hospitalizations and functional decline.
Establish clinical standards, ensure CMS compliance, and integrate AI-assisted workflows with operations and technology teams.
A healthcare organization dedicated to improving outcomes for Medicare patients through clinical leadership and technology-enabled care. It fosters a fast-paced, high-autonomy culture focused on measurable patient impact.