Regional Medical Director, Non-Acute UM & Care Optimization

alignmenthealthcare; San Antonio (TX); Vor Ort; USD 160.000 - 210.000; Vollzeit

Zusammenfassung

Alignment Health is a fast-growing organization focused on senior care and care coordination. This role leads non-acute utilization management programs, partnering with physicians, hospitals, and delegated groups to optimize referrals, prior authorizations, and medical necessity decisions.

The position emphasizes cross-functional collaboration to improve care transitions, reduce unnecessary care, and align site-of-service utilization with CMS guidelines.

Aufgaben

• Non-Acute Utilization Management Leadership. Lead physician oversight of market-level non-acute UM programs-including prior authorization, referral management, outpatient medical necessity determinations, DME, home health, advanced imaging, Part B medications, and site-of-service optimization-ensuring consistent application of CMS regulations, InterQual/MCG criteria, and evidence-based guidelines.
• Provider Engagement and Utilization Performance. Partner with PCPs, specialists, hospitals, and delegated medical groups to improve utilization performance; conduct targeted physician education on referral appropriateness, site-of-service optimization, and procedural appropriateness; and meet regularly with contracted and delegated group medical directors to align referral patterns, prior authorization workflows, and medical management priorities.
• Prior Authorization and Medical Necessity Oversight. Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient and non-acute requests; review authorization, denial, appeal, and overturn trends; support implementation of electronic prior authorization and automation initiatives; and reduce unnecessary care variation through provider education and compliance with clinical pathways. Partnering with UM operations to improve provider experience, authorization turnaround times, and first-pass approval rates. Ensuring medical decision-making incorporate member goals, prognosis, and informed consent principles. Facilitating timely transitions to lower levels of care when clinically appropriate.
• Care Transitions and Post-Discharge Coordination. Ensure effective clinical handoffs between institutional and outpatient settings by coordinating with the Regional Medical Officer, Transition of Care, and Care Anywhere teams; establish prioritization of post-acute outreach based on member risk stratification; and monitor and address barriers contributing to avoidable readmissions, ED utilization, and gaps in care continuity. Supporting the acute UM team on post-discharge outpatient authorization needs, including DME, home health, follow-up imaging, and Part B infusions. Collaborating with providers and delegated groups to ensure post-acute plans align with member preferences, caregiver support, and community resources.
• Ambulatory and Procedural Site-of-Service Optimization. Lead physician strategy for preferred Ambulatory Surgery Center utilization and procedural appropriateness; collaborate with specialists, delegated medical groups, Network Management, and Contracting to increase use of high-quality, cost-effective sites of service; and identify opportunities to reduce low-value care, unnecessary procedural variation, and avoidable inpatient or post-acute utilization.
• Pharmacy and Specialty Medication Integration. Partner with Pharmacy leadership and the PBM on utilization management and optimization of Part B medications and infusion therapies; ensure members receiving specialty therapies have appropriate wraparound clinical support, monitoring, and care coordination; and engage aligned and delegated providers on Part B medication management in partnership with Network Management and Contracting.
• Referral Management and Medical Management Coordination . Physician review of outpatient specialty referrals f

Jobbeschreibung

Alignment Health is a fast-growing organization focused on senior care and care coordination. This role leads non-acute utilization management programs, partnering with physicians, hospitals, and delegated groups to optimize referrals, prior authorizations, and medical necessity decisions.

The position emphasizes cross-functional collaboration to improve care transitions, reduce unnecessary care, and align site-of-service utilization with CMS guidelines.