Remote Regional Utilization Management Director

E2E Alignment Healthcare USA, LLC; Texas; Hybrid; USD 262,000 - 393,000; Full time

Job summary

Alignment Health is seeking an experienced leader in utilization management to oversee non-acute UM programs, prior authorization, and clinical decision-making. You will partner with PCPs, specialists, and delegated groups to improve utilization and site-of-service decisions.

The role requires MD/DO with Texas licensure, board certification, and strong leadership in Medicare Advantage, analytics, and quality improvement. Travel within local markets is expected.

Qualifications

• MD or DO with Texas medical license.
• Board certification in an ABMS- or AOA-recognized specialty.
• Experience in Medicare Advantage/managed care.
• Leadership experience in utilization management.

Responsibilities

• Oversee non-acute UM programs and prior authorization with CMS and InterQual/MCG criteria.
• Engage providers to optimize referral patterns and site-of-service decisions.
• Lead peer-to-peer reviews of complex outpatient and non-acute requests.
• Drive post-discharge care transitions and SNF utilization improvements.
• Monitor KPIs like MLR, authorization turnaround, and Star Ratings.
• Ensure regulatory compliance and quality oversight across UM activities.
• Support implementation of electronic prior authorization and automation.
• Coordinate with regional teams and network partners.

Skills

Medicare Advantage

Utilization Management

Prior Authorization

Provider Engagement

Clinical Analytics

Quality Improvement

Data Analysis

Executive Communication

Education

MD/DO, Texas license

Job description

Alignment Health is seeking an experienced leader in utilization management to oversee non-acute UM programs, prior authorization, and clinical decision-making. You will partner with PCPs, specialists, and delegated groups to improve utilization and site-of-service decisions.

The role requires MD/DO with Texas licensure, board certification, and strong leadership in Medicare Advantage, analytics, and quality improvement. Travel within local markets is expected.