Medical Director, Utilization Management & Quality

Altais; Sacramento (CA); Vor Ort; USD 225.000 - 275.000; Vollzeit

Benefits dieser Stelle

Excellent medical coverage

Vision and dental coverage

401(k) with company match

Paid holidays

Zusammenfassung

Altais is seeking an experienced Utilization Management, Medical Director to lead clinical oversight, quality improvement, and provider engagement across its California network. You will drive evidence-based care, utilization reviews, and population health initiatives while aligning clinical and operational priorities.

The role requires an MD or DO with board certification, a track record in leadership, and strong collaboration with care management teams and providers to ensure high-value,

Qualifikationen

• MD/DO degree from an accredited medical school
• Active and unrestricted medical license
• Board certification in a medical specialty
• Strong understanding of quality improvement methodologies and healthcare regulations
• Excellent communication, leadership, and interpersonal skills
• Ability to analyze complex clinical data and develop actionable insights
• Strong knowledge of utilization management, care management, population health, and value-based care principles
• Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines
• Experience managing provider appeals, authorization reviews, and payer interactions
• Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics
• Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement

Aufgaben

• Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services
• Develop and implement clinical protocols, guidelines, and standards
• Monitor and evaluate clinical performance metrics and outcomes
• Lead quality improvement initiatives to enhance patient care and safety
• Oversee the implementation of evidence-based practices and clinical pathways
• Conduct regular reviews of clinical data to identify areas for improvement
• Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics
• Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions
• Foster strong relationships with network physicians and healthcare providers
• Collaborate with providers to address clinical issues, improve care coordination, and promote best practices
• Facilitate educational sessions and training programs for providers
• Provide physician leadership for utilization management activities, ensuring appropriate, effective, and evidence-based use of healthcare resources
• Collaborate with care management, case management, and network providers to support high-quality, cost-effective patient care across the continuum
• Participate in appeals and peer-to-peer discussions with health plans and providers regarding medical necessity and coverage determinations when appropriate
• Provide clinical oversight and input related to high-risk patient management, transitions of care, and complex case reviews
• Support provider education regarding utilization management principles, evidence-based practice standards, and appropriate resource utilization
• Participate in Utilization Management Committee meetings and present trends and improvement opportunities

Ausbildung

MD/DO degree

Board certification

Jobbeschreibung

Altais is seeking an experienced Utilization Management, Medical Director to lead clinical oversight, quality improvement, and provider engagement across its California network. You will drive evidence-based care, utilization reviews, and population health initiatives while aligning clinical and operational priorities.

The role requires an MD or DO with board certification, a track record in leadership, and strong collaboration with care management teams and providers to ensure high-value,