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-timeNorth 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 extensive experience in Utilization Management, including oversight of non-acute care programs, compliance with CMS and NCQA regulations, and collaboration with healthcare providers to optimize referral and authorization workflows. Possesses strong analytical skills to interpret clinical and financial data, ensuring adherence to quality metrics and performance standards.

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 OptimizationQuality Performance MetricsEvidence-Based Criteria ApplicationReferral ManagementMedical Necessity ReviewsRegulatory Compliance

Soft Skills

Excellent Written CommunicationVerbal Communication SkillsPresentation SkillsCollaborationAbility To Operate In Matrixed Environments

Certifications & Qualifications

Active Medical License In North CarolinaBoard Certification In ABMS Or AOA Specialty

Industry Keywords

Medicare AdvantageHEDISStar RatingsManaged Care PrinciplesPopulation HealthHealthcare Risk ManagementPatient Safety PrinciplesReferral PatternsOutpatient Utilization TrendsQuality 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 align referral and authorization workflows
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 surgery center and procedural site-of-service optimization strategies
Partner with Pharmacy leadership and the PBM on Part B medication and infusion therapy utilization management
Oversee outpatient specialty referral medical necessity, referral workflows, referral trends, network leakage, and in-network specialist referrals
Provide physician leadership for SNF utilization management, discharge planning, length-of-stay management, preferred SNF networks, and post-acute partnerships
Lead preoperative optimization and surgical readiness activities
Monitor MLR, authorization, referral, ED, ASC, outpatient surgery, cost, readmission, and Star Ratings KPIs
Ensure clinical decisions comply with CMS, NCQA, and applicable state regulations; participate in audits, appeals, grievance reviews, and regulatory inquiries
Perform acute UM overflow duties when explicitly assigned and approved by the CDO
Maintain visible presence in assigned local markets through remote work, home-based clinical visits, in-person collaboration, patient visits, physician meetings, and delegated-group committees
Travel throughout local markets and occasionally to the corporate office and organizational events
Individual contributor role with no supervisory responsibilities

Requirements

What you’ll need

Must reside in North Carolina
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 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 and collaborate cross-functionally
Ability to perform the stated physical functions, including standing, walking, sitting, reaching, and frequently lifting or moving up to 10 pounds

Benefits

Comp & perks

Remote work with home-based clinical visits
Local-market and corporate travel opportunities
Reasonable accommodations for individuals with disabilities
Equal employment opportunity protections