Remote Regional Medical Director, Non-Acute Utilization

Alignment Healthcare USA, LLC in; San Antonio (TX); Hybrid; USD 262,000 - 393,000; Full time

Job summary

Alignment Health is a fast-growing organization seeking a Regional Medical Director, Non-Acute Utilization Management, to lead market-level UM programs across Texas. This remote-facing physician role partners with networks and delegated groups to optimize prior authorization, referrals, and outcomes while aligning with CMS criteria and evidence-based guidelines.

The role drives physician engagement, optimizes site-of-service decisions, and supports transitions of care, with a focus on improving

Qualifications

• Minimum five-ten years of Utilization Management clinical practice experience.
• Minimum three years of leadership experience within managed care environments.
• Active, unrestricted medical license in Texas.

Responsibilities

• 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.
• Partner with PCPs, specialists, hospitals, and delegated medical groups to improve utilization performance and conduct physician education on referral appropriateness and site-of-service optimization.
• Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient and non-acute requests and support implementation of electronic prior authorization initiatives.
• Ensure effective clinical handoffs between institutional and outpatient settings and monitor post-acute transitions to reduce readmissions and gaps in care continuity.
• Lead strategy for Ambulatory Surgery Center utilization, high-value sites of service, and reduction of low-value care and unnecessary variation.
• Collaborate with Pharmacy leadership, PBMs on Part B medication management and wraparound clinical support for patients on specialty therapies.
• Oversee regulatory compliance with CMS and state requirements; participate in audits, grievances, and quality improvement initiatives.

Skills

Utilization Management

Leadership

Medicare Advantage

Provider Engagement

Regulatory Compliance

Clinical Operations

Education

MD/DO degree

Board certification

Job description

Alignment Health is a fast-growing organization seeking a Regional Medical Director, Non-Acute Utilization Management, to lead market-level UM programs across Texas. This remote-facing physician role partners with networks and delegated groups to optimize prior authorization, referrals, and outcomes while aligning with CMS criteria and evidence-based guidelines.

The role drives physician engagement, optimizes site-of-service decisions, and supports transitions of care, with a focus on improving