Regional Medical Director, Non-Acute Utilization

Alignment Healthcare USA, LLC; Fresno (CA); Hybride; USD 262 000 - 393 000; Plein temps

Résumé du poste

Alignment Health is seeking a Regional Medical Director, Non-Acute Utilization Management to lead market-level non-acute UM programs and drive cost, quality, and outcomes improvements. The role partners with the Regional Medical Officer to oversee Prior Authorization, Referral Management, Utilization Management, Clinical Operations, Care Anywhere, Case Management, Pharmacy, Network Management, and Quality.

Responsibilities include aligning referral patterns, optimizing site-of-service, and

Qualifications

• MD or DO with active medical license
• Board certification in an ABMS- or AOA-recognized specialty
• Experience in Medicare Advantage operations and utilization management

Responsabilités

• Lead market-level non-acute UM programs including prior authorization and utilization reviews.
• Partner with PCPs, specialists, hospitals, and delegated medical groups to improve referral patterns and utilization.
• Oversee medical necessity reviews, denials trends, and electronic prior authorization initiatives.
• Coordinate post-discharge care transitions and SNF/post-acute utilization strategies.
• Drive site-of-service optimization and high-value ASC utilization with cost-effective vendors.
• Collaborate with Pharmacy leadership on Part B medication management and integration.
• Coordinate referral workflows and medical management with delegated groups.
• Support regulatory compliance and quality initiatives, including Star Ratings improvement.
• Lead analytics-driven performance improvement across non-acute UM metrics.

Connaissances

Leadership

Utilization Management

Medicare/MA Ops

Data analytics

Provider engagement

Formation

MD or DO

Board cert in Family/Internal Medicine

Description du poste

Alignment Health is seeking a Regional Medical Director, Non-Acute Utilization Management to lead market-level non-acute UM programs and drive cost, quality, and outcomes improvements. The role partners with the Regional Medical Officer to oversee Prior Authorization, Referral Management, Utilization Management, Clinical Operations, Care Anywhere, Case Management, Pharmacy, Network Management, and Quality.

Responsibilities include aligning referral patterns, optimizing site-of-service, and