Regional Medical Director, Non-Acute UM

Alignment Health

. Lead physician oversight of market-level non-acute utilization management programs, including prior authorization, referral management, outpatient medical necessity determinations, DME, home health, advanced imaging, Part B medications, and site-of-service optimization .

Posted 10/7/2026full-timeFresno • California • United StatesLead💰 $262,145 - $393,217 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive experience in Utilization Management, including oversight of non-acute care programs, compliance with CMS and NCQA regulations, and application of evidence-based clinical guidelines. Proven ability to analyze complex data and implement strategies for improving physician performance and patient care outcomes.

Highest-signal resume keywords

Utilization Management ExperienceMedicare Advantage OperationsClinical Practice LeadershipBoard CertificationActive Medical License

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementClinical Guidelines ApplicationData AnalysisAuthorization ReviewSite-of-Service OptimizationKPI MonitoringPeer-to-Peer ConsultationsOutpatient Referral ManagementPost-Acute Care StrategyRegulatory Compliance

Soft Skills

Excellent Communication SkillsRelationship ManagementPresentation SkillsAbility to Operate in Matrixed Environments

Certifications & Qualifications

MD or DO DegreeBoard Certification in ABMS or AOA SpecialtyActive Medical License in CA

Industry Keywords

Medicare AdvantageHEDISStar RatingsManaged CareValue-Based CarePatient Safety PrinciplesHealthcare Risk ManagementOutpatient Utilization TrendsReferral PatternsQuality Performance Metrics

About the role

Key responsibilities & impact

Lead physician oversight of market-level non-acute utilization management 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, delegated medical groups, and medical directors to improve utilization performance and physician education
Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient and non-acute requests
Review authorization, denial, appeal, and overturn trends and support electronic prior authorization and automation initiatives
Coordinate care transitions and post-discharge outreach with Regional Medical Officer, Transition of Care, and Care Anywhere teams
Lead ambulatory and procedural site-of-service optimization and preferred Ambulatory Surgery Center utilization
Partner with Pharmacy leadership and PBM on Part B medication and infusion therapy utilization management
Review outpatient specialty referrals for medical necessity and promote in-network referrals
Provide physician leadership for SNF utilization management and post-acute care strategy
Lead preoperative optimization and surgical readiness activities
Monitor KPIs including MLR, authorization and referral metrics, ED utilization, outpatient surgical utilization, costs, and Star Ratings measures
Ensure compliance with CMS, NCQA, and applicable state regulatory requirements; participate in audits, appeals, grievance reviews, and regulatory inquiries
Perform acute UM overflow duties only when explicitly assigned and approved by the CDO
Maintain local-market engagement through patient visits, physician meetings, delegated-group committees, operational initiatives, and relationship management
Travel throughout the local market and occasionally to the corporate office or organizational events
Work as an individual contributor with no supervisory responsibilities

Requirements

What you’ll need

Must reside in or near Fresno, CA
Minimum five-ten years of Utilization Management clinical practice experience
Minimum three years of leadership experience within managed care, Medicare Advantage, physician organizations, IPA/MSO, or value-based care environments
MD or DO degree from an accredited institution
Board certification in an ABMS- or AOA-recognized specialty
Active, unrestricted medical license in applicable state CA
Demonstrated working knowledge of Medicare Advantage operations, managed care principles, and CMS regulatory requirements applicable to utilization management, quality, and population health
Comprehensive knowledge of Medicare Advantage operations, utilization management, Star Ratings, HEDIS, and value-based care performance metrics
Ability to apply evidence-based criteria, clinical guidelines, and CMS-compliant standards to complex authorization decisions across the non-acute continuum
Ability to interpret complex clinical, financial, and quality performance data and translate findings into provider-facing improvement strategies
Demonstrated experience working with physicians, provider groups, delegated medical groups, and executive stakeholders
Working knowledge of outpatient and non-acute utilization trends, site-of-service optimization, readmission drivers, referral patterns, and medical expense management
Knowledge of HEDIS, CAHPS, HOS, and Star Ratings program requirements
Knowledge of healthcare risk management frameworks and patient safety principles
Excellent written, verbal, and presentation skills
Proven ability to operate in matrixed environments
Ability to meet essential physical functions, including standing, walking, sitting, handling objects, reaching, and lifting/moving up to 10 pounds

Benefits

Comp & perks

Remote work
Home-based clinical visits
Regular in-person collaboration
Occasional travel to the corporate office and organizational meetings or events
Reasonable accommodations for individuals with disabilities