Associate Chief Medical Officer, Medicare Advantage

​​At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s 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 member’s complete health history, we ensure better care at a lower cost—delivering 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 Clover’s 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 Health’s 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 Health’s 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 Health's 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: You've 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 you've significantly contributed to the ongoing evolution of Clover’s 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 physi