• The Medical Director, Utilization Management, will be responsible for the evaluation of all outpatient referrals and inpatient direct admissions for medical appropriateness. • The physician will utilize Local and National Medicare Coverage Determinations, Milliman Care Criteria, Clover Health’s medical policies reviews to determine medical necessity or if an alternate treatment plan is required for our members. • Successfully completes all required new hire training modules and certifications • Demonstrates a foundational understanding of Clover Health's medical policies, guidelines, and utilization management processes • Begins to independently review cases with increasing efficiency and accuracy, requiring minimal oversight • Establishes positive working relationships with team members and key stakeholders • Consistently meets or exceeds productivity targets for case reviews and determinations • Maintains a high level of accuracy in medical necessity determinations and documentation • Actively participates in team meetings and contributes to process improvement discussions • Demonstrates a comprehensive understanding of complex medical cases and escalates issues appropriately.