Remote Regional Medical Director, Non-Acute Utilization

Alignment Health; San Antonio (TX); Hybrid; USD 262,000 - 393,000; Full time

Job summary

Alignment Health in Texas seeks a Regional Medical Director, Non-Acute Utilization Management, to lead market-level utilization programs across provider networks. The role partners with leadership to optimize prior authorization, referral management, and non-acute care decisions.

You will drive clinician engagement, care transitions, site-of-service optimization, and analytics to improve MLR, Star Ratings, and member outcomes.

Qualifications

• MD or DO with active Texas license; Board certified in a primary care or internal medicine specialty.
• 5–10 years of Utilization Management clinical practice experience.
• 3+ years of leadership in managed care, Medicare Advantage, IPA/MSO, or risk-bearing environments.
• Experience supporting Medicare Star Ratings initiatives and HEDIS knowledge.

Responsibilities

• Lead physician oversight of market-level non-acute UM programs and prior authorization workflows.
• Engage providers to improve referral patterns, site-of-service optimization, and medical management.
• Oversee medical necessity reviews, authorization trends, and electronic prior authorization efforts.
• Coordinate post-discharge care transitions and SNF utilization strategies.
• Drive ambulatory site-of-service optimization and high-value facility utilization.
• Collaborate with Pharmacy and Network Management on Part B medication management.
• Review referrals for medical necessity and promote in-network utilization.
• Monitor KPIs (MLR, approval/denial rates, readmissions, Star Ratings) and drive improvements.

Skills

Medicare Advantage

Utilization Management

Provider engagement

Clinical analytics

Star Ratings

Quality improvement

Communication skills

Cross-functional collaboration

Education

MD or DO

Board certification ABMS/AOA

Active Texas medical license

Board certification Family/Internal Medicine

Job description

Alignment Health in Texas seeks a Regional Medical Director, Non-Acute Utilization Management, to lead market-level utilization programs across provider networks. The role partners with leadership to optimize prior authorization, referral management, and non-acute care decisions.

You will drive clinician engagement, care transitions, site-of-service optimization, and analytics to improve MLR, Star Ratings, and member outcomes.