Utilization Management, Medical Director

Altais; Sacramento (CA); On-site; USD 225,000 - 275,000; Full time

Benefits offered by this job

Excellent medical coverage

Vision and dental coverage

401(k) with company match

Paid holidays

Job summary

Altais is seeking an experienced Utilization Management, Medical Director to lead clinical oversight, quality improvement, and provider engagement across its California network. You will drive evidence-based care, utilization reviews, and population health initiatives while aligning clinical and operational priorities.

The role requires an MD or DO with board certification, a track record in leadership, and strong collaboration with care management teams and providers to ensure high-value,

Qualifications

• MD/DO degree from an accredited medical school
• Active and unrestricted medical license
• Board certification in a medical specialty
• Strong understanding of quality improvement methodologies and healthcare regulations
• Excellent communication, leadership, and interpersonal skills
• Ability to analyze complex clinical data and develop actionable insights
• Strong knowledge of utilization management, care management, population health, and value-based care principles
• Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines
• Experience managing provider appeals, authorization reviews, and payer interactions
• Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics
• Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement

Responsibilities

• Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services
• Develop and implement clinical protocols, guidelines, and standards
• Monitor and evaluate clinical performance metrics and outcomes
• Lead quality improvement initiatives to enhance patient care and safety
• Oversee the implementation of evidence-based practices and clinical pathways
• Conduct regular reviews of clinical data to identify areas for improvement
• Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics
• Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions
• Foster strong relationships with network physicians and healthcare providers
• Collaborate with providers to address clinical issues, improve care coordination, and promote best practices
• Facilitate educational sessions and training programs for providers
• Provide physician leadership for utilization management activities, ensuring appropriate, effective, and evidence-based use of healthcare resources
• Collaborate with care management, case management, and network providers to support high-quality, cost-effective patient care across the continuum
• Participate in appeals and peer-to-peer discussions with health plans and providers regarding medical necessity and coverage determinations when appropriate
• Provide clinical oversight and input related to high-risk patient management, transitions of care, and complex case reviews
• Support provider education regarding utilization management principles, evidence-based practice standards, and appropriate resource utilization
• Participate in Utilization Management Committee meetings and present trends and improvement opportunities

Education

MD/DO degree

Board certification

Job description

At Altais, we’re on a mission to improve the healthcare experience for everyone - starting with the people who deliver it. We believe physicians should spend more time with patients and less time on administrative tasks. Through smarter technology, purpose-built tools, and a team-based model of care, we help doctors do what they do best: care for people.

Altais includes a network of physician-led organizations across California, including Brown & Toland Physicians, Altais Medical Group Riverside, and Family Care Specialists. Together, we’re building a stronger, more connected healthcare system.

About the Role

Are you looking to join a fast-growing, dynamic team?

We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients.

The Utilization Management, Medical Director is a key physician responsible for advancing clinical excellence, quality outcomes, utilization management, and provider engagement across the network. This role provides clinical oversight, supports evidence-based care delivery, and partners with providers, care management teams, and operational leaders to improve healthcare quality, patient outcomes, and effective stewardship of healthcare resources. The Medical Director helps ensure compliance with regulatory requirements, supports utilization and population health initiatives, and contributes to strategic growth through provider recruitment, retention, and network development. With a focus on aligning clinical, operational, and organizational priorities, this role serves as a trusted physician leader in advancing value-based care and high-performing provider networks.

You will focus on:

Clinical Leadership:

• Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services.


• Develop and implement clinical protocols, guidelines, and standards.


• Monitor and evaluate clinical performance metrics and outcomes.

Quality Improvement:

• Lead quality improvement initiatives to enhance patient care and safety.


• Oversee the implementation of evidence-based practices and clinical pathways.


• Conduct regular reviews of clinical data to identify areas for improvement.


• Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics.


• Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions.

Provider Relations:

• Foster strong relationships with network physicians and healthcare providers.


• Collaborate with providers to address clinical issues, improve care coordination, and promote best practices.


• Facilitate educational sessions and training programs for providers.


• Provide physician leadership for utilization management activities, ensuring appropriate, effective, and evidence-based use of healthcare resources.


• Collaborate with care management, case management, and network providers to support high-quality, cost-effective patient care across the continuum.


• Participate in prospective, concurrent, and retrospective utilization review activities, including review of medical necessity determinations, treatment plans, hospital admissions, and specialty referrals.


• Serve as a clinical resource for complex utilization, authorization, and care management cases.


• Support development, implementation, and ongoing refinement of utilization management policies, procedures, clinical criteria, and authorization guidelines.


• Analyze utilization trends, referral patterns, inpatient and outpatient utilization data, and opportunities for improved care coordination and resource stewardship.


• Partner with operational and clinical leaders to achieve utilization, quality, and population health performance goals.


• Participate in appeals and peer-to-peer discussions with health plans and providers regarding medical necessity and coverage determinations when appropriate.


• Provide clinical oversight and input related to high-risk patient management, transitions of care, and complex case reviews.


• Support provider education regarding utilization management principles, evidence-based practice standards, and appropriate resource utilization.

Utilization Management Committee Leadership

• Participate in and/or chair Utilization Management Committee meetings as assigned.


• Present utilization trends, performance metrics, and improvement opportunities to clinical and operational leadership.


• Provide clinical leadership in the development of UM strategies that improve outcomes while maintaining responsible stewardship of healthcare resources.


• Collaborate with Quality, Population Health, and Care Management teams to align utilization management activities with organizational goals.

Compliance and Regulation:

• Ensure compliance with all regulatory requirements and industry standards.


• Stay updated on changes in healthcare regulations and implement necessary adjustments.


• Manage audits and accreditation processes.

Strategic Planning and Network Growth:

• Contribute to the development and execution of the IPA's strategic plan.


• Identify opportunities for growth and expansion of services.


• Collaborate with executive leadership to align clinical goals with organizational objectives.


• Participate in network expansion efforts through presentations, outreach to strategic provider prospects

Provider Recruitment and Retention

• Participate in recruitment outreach activities, employment fairs, residency program events, other events as identified/prioritized by President, SCAL Network


• Actively participate in all physician candidate interviews, once physician has passed through initial screening


• Develop and maintain relationship with physician candidates in final round of selection process, and throughout onboarding process if/when hired


• Participate in onboarding/orientation of new physicians after start date


• Serve as AMG Friendly Physician for Southern California Region

The Skills, Experience & Education You Bring

• MD or DO degree from an accredited medical school


• Active and unrestricted medical license


• Minimum of 5 years of clinical experience, with at least 3 years in a leadership role


• Required Certification: Board certification in a medical specialty


• Strong understanding of quality improvement methodologies and healthcare regulations.


• Excellent communication, leadership, and interpersonal skills.


• Ability to analyze complex clinical data and develop actionable insights.


• Strong knowledge of utilization management, care management, population health, and value-based care principles.


• Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines.


• Experience managing provider appeals, authorization reviews, and payer interactions.


• Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics.


• Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement.

The Compensation for this position is $225,000 to $275,000/year

In addition, we provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.

• Excellent medical, vision, and dental coverage


• 401k savings plan with a company match


• Flexible time off and 9 Paid Holidays

You Share Our Mission & Values:

Compassion

We act with empathy and a deep respect for the challenges faced by physicians and their patients. Our work is driven by a genuine commitment to improving lives and ensuring that care is delivered with dignity, understanding, and humanity.

Community

We foster a culture of collaboration - with physicians, patients across the healthcare ecosystem, and among our teams. By building strong, trusted relationships, we create a unified community focused on advancing patient care and physician well-being.

Leadership

We lead with integrity and vision, setting the standard for excellence in physician support and healthcare innovation. Through collaboration and expertise, we empower others to lead, drive change, and shape the future of care.

We are relentlessly focused, results-driven, and accountable for delivering measurable value to physicians and the patients they serve. Our high standards reflect our commitment to excellence, operational discipline, and continuous improvement.

Agility

We embrace change as a constant and respond swiftly to the evolving needs of the healthcare industry. With flexibility and forward-thinking, we adapt, innovate, and act decisively to keep physicians at the forefront.

Altais and its subsidiaries and affiliates are committed to protecting the privacy and security of the personal information you provide to us. Please refer to our ‘CPRA Privacy Notice for California Employees and Applicants’ to learn how we collect and process your personal information when you apply for a role with us.

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity or disability status and any other classification protected by Federal, State and local laws.