Medical Director MAPD

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We? ✨

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Medical Director is a full-time physician leader and operational partner across Clever Care Health Plan’s (MAPD) clinical operations. This hands-on role is focused on real-time clinical decision-making, issue resolution, and practical support for teams, with opportunities to contribute to broader leadership and program work. It combines thoughtful case-level decision-making with physician oversight of Utilization Management, Care Management, appeals and grievances, quality-of-care review, delegated clinical functions, and regulatory readiness. The Medical Director works closely with clinical and operational teams to solve problems, improve access and outcomes, and ensure decisions are timely, practical, well documented, and centered on the needs of our members.

The role also helps shape programs and workflows that reflect the cultural, language, family, and community context of the diverse populations we serve. The Medical Director brings sound clinical judgment, curiosity, and a collaborative approach to translating regulatory and clinical requirements into care that is both compliant and culturally attuned. This is a visible, accessible leadership position for a physician who enjoys working through real cases, connecting with people, and serving as an approachable partner to teams across the organization.

Core Responsibilities

UM Reviews & Clinical Decision-Making

• Help ensure members experience clinical care that is safe, compassionate, timely, culturally attuned, and centered on their individual needs.
• Build and maintain collaborative relationships with provider groups and individual providers to support ongoing, practical conversations about UM issues that require timely clinical input and quick resolution.
• Review UM cases including prior authorizations, secondary reviews, and medical necessity questions.
• Make thoughtful, medically appropriate decisions that balance clinical evidence, plan requirements, and the member’s individual needs.
• Use CMS rules, plan criteria, and clinical guidelines in a consistent and well-documented way.
• Support peer-to-peer discussions and help work through complex or escalated cases.
  
  

Care Management & Population Health

• Partner with Care Management and Population Health leadership to provide physician guidance on clinical programs, workflows, and member care strategies.
• Provide clinical oversight and physician guidance for Health Risk Assessments (HRAs), Individualized Care Plans (ICPs), Interdisciplinary Care Team (ICT) activities, and Transitions of Care (TOC) to ensure clinical appropriateness, regulatory compliance, and high-quality member care.
• Participate in discussions regarding complex member cases, barriers to care, and opportunities to improve care coordination and member outcomes.
• Collaborate on development of clinical programs focused on chronic disease management, preventive care, quality improvement, and health equity initiatives.
  
  

Appeals, Grievances & Quality-of-Care Review

• Review clinical appeals and grievances, including member, provider, and pharmacy-related cases.
• Participate in regulatory, external, and other appeals processes at all levels, including providing physician input, supporting case preparation, and participating in hearings or other formal review proceedings when appropriate.
• Participate in quality-of-care reviews, focused case reviews, and case discussions when physician input is needed.
• Make sure decisions are timely, clinically sound, and easy to follow in the documentation.
  
  

Pharmacy

• Provide physician oversight and clinical partnership for pharmacy-related utilization management, appeals, quality initiatives, medication adherence, and medication safety activities.
• Collaborate with Pharmacy leadership on coverage criteria, formulary-related clinical questions, Part D and pharmacy benefit issues, and escalated member or provider concerns.
• Support pharmacy-related audit readiness, regulatory responses, delegation oversight, and committee work where physician input is needed.
  
  

Delegation Oversight

• Provide physician oversight of delegated and internal clinical functions, including Utilization Management, Care Management, Pharmacy, Quality, Population Health, and SNP Model of Care activities. Participate in delegation assessments, performance monitoring, corrective action planning, and ongoing oversight.
• Participate in pre-delegation reviews, annual audits, CAP follow-up, and routine performance monitoring.
• Raise concerns early when there are clinical, compliance, quality, documentation, or member-safety issues.
  
  

CMS Audit & Committee Support

• Help prepare for and support CMS program audits, validation audits, mock audits, and other regulatory reviews.
• Review samples, determinations, documentation, and universes to make sure they are accurate and audit-ready.
• Chair the UM/QM Committee and participate in IRR, Credentialing, P&T, QM, and other committees or workgroups where physician input is needed or as assigned.
• Serve as the physician representative during CMS, NCQA, and regulatory audits, including supporting audit interviews, universes, and corrective action plan development.
  
  

Working Across Teams

• Work collaboratively with the CMIO, Care Management, Population Health, Utilization Management, Pharmacy, Quality, Compliance, and Operations to align clinical priorities with operational workflows. Serve as an accessible physician partner who provides timely clinical guidance, supports process improvement, and helps resolve operational barriers.
• Assist the CMIO in the clinical enablement of innovative, technology-forward programs, including helping translate clinical priorities into practical workflows, tools, and implementation support.
• Flag potential FWA, compliance, quality, or documentation issues that come up through case review or oversight work.
• Participate in clinical reviews for Special Investigations Unit (SIU) cases when physician input is needed to evaluate fraud, waste, and abuse (FWA) concerns.
  
  

Clinical Leadership

• Foster collaborative relationships with clinical and operational leaders to support organizational priorities and continuous improvement.
• Provide physician mentorship and consultation to nursing, pharmacy, and interdisciplinary teams.
• Champion a culture of quality, compliance, accountability, and member-centered care.
  
  

Qualifications

Qualifications

• MD or DO with active unrestricted medical license; board certification in Internal Medicine, Family Medicine, or Geriatrics preferred. Geriatrics training or experience with older adult populations is strongly preferred.
• 5+ years of Medicare Advantage experience preferred, ideally with prior Medical Director or Physician Advisor experience in a health plan, delegated group, IPA, or similar setting.
• Experience with UM cases, appeals, delegation oversight, CMS audits, coverage criteria, medical necessity review, and clinical documentation standards.
• Strong clinical judgment, clear written communication, and a collaborative, approachable style; enjoys staying connected to the team, talking through real cases with colleagues, and helping solve day-to-day clinical and operational issues.
• Comfortable working with technology, multiple sources of clinical and operational information, and various health plan, provider, vendor, and regulatory portals; open to using innovative tools to improve workflows, decision-making, and member care.
  
  

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.