Regional UM Leader — Non-Acute Care & Transitions

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

Résumé du poste

Alignment Health is seeking a senior Utilization Management Leader to guide market-level non-acute UM programs, physician oversight, and prior authorization in the Fresno, CA area. You will align with CMS and evidence-based guidelines while partnering with PCPs, hospitals, and delegated medical groups to optimize utilization.

The role requires MD/DO with CA license, leadership in managed care, and strong analytics to improve performance and member outcomes in a local-market setting.

Qualifications

• MD/DO required with active license in CA.
• Board certification in an ABMS- or AOA-recognized specialty.
• Strong leadership experience in managed care or Medicare Advantage.

Responsabilités

• Lead physician oversight of non-acute UM programs and prior authorization.
• Engage providers to improve utilization, referrals, and site-of-service decisions.
• Oversee medical necessity reviews and authorization trends with CMS criteria.
• Coordinate post-acute transitions and care continuity across networks.
• Monitor KPIs (MLR, authorization rates, readmissions) and drive improvements.

Connaissances

Medicare Advantage operations

Utilization management

Provider engagement

Data analysis

Leadership

CMS regulations

Formation

MD or DO degree

Board certification

Medical license (CA)

Description du poste

Alignment Health is seeking a senior Utilization Management Leader to guide market-level non-acute UM programs, physician oversight, and prior authorization in the Fresno, CA area. You will align with CMS and evidence-based guidelines while partnering with PCPs, hospitals, and delegated medical groups to optimize utilization.

The role requires MD/DO with CA license, leadership in managed care, and strong analytics to improve performance and member outcomes in a local-market setting.