Medical Director, Utilization Management-Remote

Alignment Health; Northern (KY); Hybrid; USD 262,000 - 393,000; Full time

Job summary

Alignment Health is seeking a Remote UM Medical Director/Physician Advisor to lead utilization management for inpatients, outpatients, and facilities, ensuring medical necessity and compliance. You will perform reviews, assign care levels, and collaborate with medical staff and payers to promote appropriate care.

The role reports to the Senior VP of Clinical Operations, with remote access to Alignment Health’s web‑based portal and a focus on quality outcomes, training, and interdisciplinary

Qualifications

• 3–5 years hospital-wide or skilled nursing facility clinical care, quality management, utilization and case management.
• Completion of medical school and specialty residency (preferably internal medicine). Board Certification.
• Current, non‑restricted medical license for the state of practice.

Responsibilities

• Conduct second level reviews for inpatient, outpatient, Skilled Facility levels of care and Pharmacy per Medicare/CMS and Milliman guidelines.
• Provide appropriate level of care classifications and continued stay reviews.
• Liaise with medical staff, utilization review and third-party payers to promote appropriate levels of medical care.
• Review the entire claim denial process, including pending claims, appeals and grievances.
• Serve as a Physician member of the Utilization Review team.
• Ensure appropriate service utilization by monitoring over- and under-utilization.
• Develop UM protocols with Interdisciplinary Team and conduct training.
• Serve as Subject Matter Expert during concurrent reviews.
• Chair Medical Quality Committee and provide clinical oversight of outcomes.

Skills

Communication skills

Attention to detail

Team collaboration

Interpersonal skills

Education

Medical degree

Residency in internal medicine

Board certification

State medical license

Job description

Remote UM Medical Director/ Physician Advisor (UM MD/PA)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Remote UM Medical Director/ Physician Advisor (UM MD/PA) reports to the Senior VP of Clinical Operations with accountability to the Chief Financial Officer and Chief Medical Officer. The UM Medical Director/Physician Advisor works with UM licensed staff, Regional Medical Officers and Extensivists to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided. Through remote access to our web-based Portal, UM Medical Director/Physician Advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance.

GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO)

• Second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
• Provide appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
• Act as a liaison between the medical staff, utilization review and third‑party payers to effectively promote the appropriate levels of medical care.
• Review the entire claim denial process, including pending claims, Appeals and Grievances.
• Serve as a Physician member of the utilization review team.
• Ensure appropriate service utilization by monitoring over‑and under‑utilization.
• Work with Interdisciplinary Team to develop AHC Utilization Management protocols, including auto‑approvals and market specific protocols.
• Develop training material and assisting UM Manager to conduct Physicians' annual Interrater reliability testing.
• Serve as a Subject Mater Expert (CME) to Regional Medical Officers and/or Extensivists during concurrent reviews.
• Serve as a Chairperson for Medical Quality Committee and provide Clinical Oversight of Quality Outcomes.
• Collaborates closely and assist Quality Director.
• Work with Provider Relation, Network Management and local Regional Medical Officers to ensure community Physician education on UM processes and regulations.
• Assist the organization to challenge physician practices in order to achieve the organization’s clinical outcomes and collaborates closely and assists Quality Director SUPERVISORY RESPONSIBILITIES: UM Clinical Staff Oversight

SUPERVISORY RESPONSIBILITIES

UM Clinical Staff Oversight

MINIMUM REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Minimum Experience: Required: 3‑5 years of experience in hospital‑wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required. Preferred: Experience as a Physician Advisor Education/Licensure: Required: Completion of medical school and specialty residency (preferably in internal medicine). Board Certification. Current, non‑restricted licensure as required for clinical practice in the State or US territory in which medical decisions are being made. Preferred: Subspecialty or other post‑residency fellowship. Specialized Skills: Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management. Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations. Dedication to the delivery of high‑quality, cost‑effective, efficient patient care services Excellent communication skills Great attention to detail as well as taking pride in being a good team member and communicate effectively with medical staff. Mon‑ Fri 8‑ 5PM with some weekend requirements. Flexible schedule

ESSENTIAL PHYSICAL FUNCTIONS

1. While performing the duties of this job, the employee is regularly required to talk or hear.
2. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
3. The employee frequently lifts and/or moves up to 10 pounds.
4. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $262,145.00 - $393,217.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

Alignment Health is championing a new path in senior care that empowers members to age well and live their most vibrant lives. Our mission‑focused team makes high‑quality, low‑cost care a reality for members every day. Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. We believe that great work comes from people who are inspired to be their best. We've built a team of people who want to make a difference in the lives of the seniors we serve. Come join the team that is changing health care — one person at a time.