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-timeCharlotte • North Carolina • United StatesLead💰 $262,145 - $393,217 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Utilization Management, including oversight of non-acute care programs, compliance with CMS and NCQA standards, and collaboration with healthcare providers to optimize patient care and resource utilization. Possesses strong analytical skills to interpret clinical and financial data, ensuring adherence to quality metrics and regulatory requirements.

Highest-signal resume keywords

Utilization Management ExperienceLeadership in Managed CareMD or DO DegreeBoard Certification in SpecialtyKnowledge of Medicare Advantage Operations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementClinical Practice ExperienceAuthorization Decision-MakingData InterpretationSite-of-Service OptimizationReferral ManagementQuality Performance MetricsEvidence-Based Criteria ApplicationRegulatory CompliancePatient Safety Principles

Soft Skills

Excellent Communication SkillsCollaborative TeamworkPresentation SkillsMatrixed Environment AdaptabilityRelationship Management

Certifications & Qualifications

Active Medical License in North CarolinaBoard Certification in ABMS or AOA Specialty

Industry Keywords

Medicare AdvantageHEDISStar RatingsManaged Care PrinciplesPopulation HealthClinical GuidelinesQuality MetricsRisk Management FrameworksOutpatient CareNon-Acute Care

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 contracted providers to improve utilization performance and provide 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 activities 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
Oversee outpatient specialty referral medical necessity, referral workflows, network leakage, and in-network referral capture
Provide physician leadership for post-acute care strategy and SNF utilization management
Lead preoperative optimization and surgical readiness within assigned markets
Monitor KPIs including MLR, authorization and referral metrics, ED utilization, ASC and outpatient surgical utilization, costs, and Star Ratings measures
Ensure clinical decisions comply with CMS, NCQA, and applicable state regulatory requirements
Perform acute UM overflow duties when explicitly assigned and approved by the CDO
Maintain visible presence in assigned local markets through patient visits, physician meetings, delegated-group committees, operational initiatives, and relationship management
Travel throughout local markets and occasionally to the corporate office and other organizational meetings or events
Work as an individual contributor with no supervisory responsibilities

Requirements

What you’ll need

Must reside in North Carolina, preferably Raleigh or Charlotte
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 North Carolina
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
Ability to interpret complex clinical, financial, and quality performance data
Demonstrated experience working collaboratively 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 perform required physical functions, including frequent lifting and/or moving up to 10 pounds

Benefits

Comp & perks

Remote work
Home-based clinical visits
Opportunity for growth and innovation
Equal Opportunity/Affirmative Action employment