Provide clinical leadership in utilization management, including medical necessity reviews and prior authorization decisions.
Engage in peer-to-peer discussions with practitioners to explain clinical rationales and explore alternative care options.
Collaborate cross-functionally to improve utilization management processes, develop medical policies, and participate in quality improvement initiatives.
This healthcare organization specializes in utilization management and clinical oversight, ensuring medical necessity and quality care. It is a fast-growing company with a collaborative, member-focused culture and a remote-first work environment.
Evaluate outpatient referrals and inpatient admissions for medical appropriateness and medical necessity.
Manage a team of UM Medical Directors and review complex or escalated cases.
Chair the UM Committee and support policy development, quality, and credentialing.
Clover Health provides healthcare plans for America's seniors, using data and technology through the Clover Assistant to support physicians. The company is mission-driven and diverse, focused on improving members' lives through personalized care.
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.
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.