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 10/27/2026full-timeTexas • 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 collaboration with healthcare providers. Possesses strong analytical skills to interpret clinical and financial data while leading initiatives to optimize patient care and resource utilization.

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

Clinical Practice ExperienceMedical Necessity DeterminationsAuthorization ReviewData InterpretationEvidence-Based Criteria ApplicationQuality Performance MetricsSite-Of-Service OptimizationReferral ManagementPost-Acute Care StrategySurgical Readiness Activities

Soft Skills

Excellent Communication SkillsCollaborative TeamworkPresentation SkillsRelationship ManagementAbility To Operate In Matrixed Environments

Certifications & Qualifications

Active Medical License In TexasBoard Certification In ABMS Or AOA Specialty

Industry Keywords

Medicare AdvantageCMS Regulatory RequirementsHEDISStar RatingsValue-Based CareManaged Care PrinciplesHealthcare Risk ManagementPatient Safety PrinciplesOutpatient Utilization TrendsClinical Guidelines

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 group 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; 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 surgery center utilization and procedural appropriateness strategy
Partner with Pharmacy leadership and PBM on Part B medication and infusion therapy utilization management
Review outpatient specialty referrals for medical necessity and resolve referral disputes
Provide physician leadership for post-acute care strategy and SNF utilization management
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
Travel throughout local markets for patient visits, physician meetings, delegated-group committees, operational initiatives, and relationship management
Collaborate independently and across geographically dispersed teams; no supervisory responsibilities

Requirements

What you’ll need

Must reside in Texas
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 Texas
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
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 meet the stated physical requirements, including standing, walking, sitting, hand and finger use, reaching, and frequent lifting/moving up to 10 pounds