Regional Medical Director, Non-Acute UM (Fresno, CA)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.The Regional Medical Director, Non-Acute Utilization Management (RMD Non-Acute UM) is a market-facing physician leader responsible for optimizing clinical outcomes, quality performance, utilization management, and total cost of care through non-acute clinical programs across assigned provider networks and markets. The role partners closely with the Regional Medical Officer and serves as the primary physician leader for Prior Authorization, Referral Management, Utilization Management, Clinical Operations, Care Anywhere (CAW), Case Management, Pharmacy, Network Management, and Quality. The RMD Non-Acute UM works directly with contracted network providers, delegated medical groups, and de-delegated non-acute functions to advance MLR, Star Ratings, member experience, and value-based care performance. Key outcomes include appropriate resource utilization, reduced avoidable post-acute placement, improved in-network referral capture, and measurable improvement in non-acute cost and quality performance.

Job Responsibilities:

Non-Acute Utilization Management Leadership. Lead physician oversight of market-level non-acute UM programs—including prior authorization, referral management, outpatient medical necessity determinations, DME, home health, advanced imaging, Part B medications, and site-of-service optimization—ensuring consistent application of CMS regulations, InterQual/MCG criteria, and evidence-based guidelines.

Provider Engagement and Utilization Performance. Partner with PCPs, specialists, hospitals, and delegated medical groups to improve utilization performance; conduct targeted physician education on referral appropriateness, site-of-service optimization, and procedural appropriateness; and meet regularly with contracted and delegated group medical directors to align referral patterns, prior authorization workflows, and medical management priorities.

Prior Authorization and Medical Necessity Oversight. Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient and non-acute requests; review authorization, denial, appeal, and overturn trends; support implementation of electronic prior authorization and automation initiatives; and reduce unnecessary care variation through provider education and compliance with clinical pathways. Partnering with UM operations to improve provider experience, authorization turnaround times, and first-pass approval rates. Ensuring medical decision-making incorporates member goals, prognosis, and informed consent principles. Facilitating timely transitions to lower levels of care when clinically appropriate.

Care Transitions and Post-Discharge Coordination. Ensure effective clinical handoffs between institutional and outpatient settings by coordinating with the Regional Medical Officer, Transition of Care, and Care Anywhere teams; establish prioritization of post-acute outreach based on member risk stratification; and monitor and address barriers contributing to avoidable readmissions, ED utilization, and gaps in care continuity. Supporting the acute UM team on post-discharge outpatient authorization needs, including DME, home health, follow-up imaging, and Part B infusions. Collaborating with providers and delegated groups to ensure post-acute plans align with member preferences, caregiver support, and community resources.

Ambulatory and Procedural Site-of-Service Optimization. Lead physician strategy for preferred Ambulatory Surgery Center utilization and procedural appropriateness; collaborate with specialists, delegated medical groups, Network Management, and Contracting to increase use of high-quality, cost-effective sites of service; and identify opportunities to reduce low-value care, unnecessary procedural variation, and avoidable inpatient or post-acute utilization.

Pharmacy and Specialty Medication Integration. Partner with Pharmacy leadership and the PBM on utilization management and optimization of Part B medications and infusion therapies; ensure members receiving specialty therapies have appropriate wraparound clinical support, monitoring, and care coordination; and engage aligned and delegated providers on Part B medication management in partnership with Network Management and Contracting.

Referral Management and Medical Management Coordination . Physician review of outpatient specialty referrals for medical necessity. Coordination of referral workflows with delegated groups aligned to benefit design. Partnering with delegated groups on shared medical management, referral trending, over/under-utilization, and network leakage. Peer-to-peer discussions with referring and consulting physicians to resolve referral disputes. Collaboration with Network Management to promote in-network referrals to preferred, high-value specialists.

Skilled Nursing Facility (SNF) Management-Acute Overflow Only. Physician leadership for post-acute care strategy and SNF utilization management. Discharge planning beginning on day of admission. Length-of-stay management and community transition support. Monitoring SNF LOS, readmission rates, discharge disposition, appeal rates, and member outcomes. Peer-to-peer reviews for direct-to-SNF admissions and complex placements. Developing preferred SNF networks and post-acute provider partnerships.

Preoperative Assessment and Surgical Readiness. Serve as the clinical lead for preoperative optimization within assigned markets by identifying members scheduled for elective procedures who need medical optimization; coordinating cardiovascular, pulmonary, diabetes, anticoagulation, frailty, and nutritional assessments with surgeons, specialists, PCPs, and pharmacists; and reducing preventable surgical complications, readmissions, and unnecessary post-acute utilization through comprehensive preoperative planning.

Performance Analytics and Improvement. Monitor and act on KPIs including MLR, authorization volume, approval/denial/appeal/overturn rates, referral volume and in-network capture rate, ED visits per thousand, ASC and outpatient surgical utilization, non-institutional costs, and Star Ratings measures including Plan All-Cause Readmissions (PCR); and partner with analytics and operational leaders to evaluate program effectiveness and drive continuous improvement.

Regulatory, Compliance, and Quality Oversight. Ensure all clinical decisions comply with CMS, NCQA, and applicable state regulatory requirements; participate in audits, appeals, grievance reviews, and regulatory inquiries; and support quality improvement initiatives that improve patient safety, outcomes, and member experience.

Acute UM Overflow — As Directed and Approved. When explicitly assigned acute UM overflow duties by the UM team and approved by the CDO, perform SNF concurrent review, peer-to-peer consultations, and length-of-stay determinations for acute admissions, direct-to-SNF placements, LTAC admissions, acute rehabilitation, and tertiary transfers using acute UM criteria and escalation pathways; these are not standing responsibilities of the RMD Non-Acute UM.

Other duties, tasks, projects and responsibilities may be assigned as needed.

Supervisory Responsibilities:

This role is an individual contributor role with no supervisory responsibilities.

Required Travel

This is a local-market position requiring a combination of remote work, home-based clinical visits, and regular in-person collaboration. The RMD Non-Acute UM is expected to maintain a visible presence within assigned local market(s) and regularly engage with CAW, TOC, Clinical Operations, UM, and Network partners, as well as direct network providers and delegated medical group leadership.

Routine travel throughout the local market(s) is required to support patient visits, physician meetings, delegated-group joint operating committees, operational initiatives, and relationship management activities. Occasional travel to the corporate office and other organizational meetings or events is also required.

This role requires the ability to operate effectively both independently and collaboratively across geographically dispersed teams while maintaining strong local-market engagement and accountability.

Job Requirements:

Experience:

Required:

• 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.

Preferred:

• Experience supporting delegated provider groups, IPAs, ACOs, or risk-bearing entities, including direct medical management engagement with delegated group medical directors and physician leaders.

• Prior leadership experience supporting Medicare Star Ratings improvement initiatives.

• Familiarity with clinical analytics, utilization trending, and provider scorecard methodologies.

• Experience with outpatient prior authorization and referral management workflows.

Education:

Required:

• MD or DO degree from an accredited institution.

• Board certification in an ABMS- or AOA-recognized specialty.

• Active, unrestricted medical license in applicable state(s).

Preferred:

• Board certification in Family Medicine or Internal Medicine.

Training:

Required:

• Demonstrated working knowledge of Medicare Advantage operations, managed care principles, and CMS regulatory requirements applicable to utilization management, quality, and population health.

Preferred:

• Ambulatory or outpatient practice experience; hospitalist or SNF experience is helpful for acute overflow assignments.

• Formal training in quality improvement methodologies, population health management, or managed care operations.

• Familiarity with HEDIS, Star Ratings, risk adjustment, and value-based care performance frameworks.

Specialized Skills:

Required:

• Medicare Advantage and Managed Care Operations: Comprehensive knowledge of Medicare Advantage operations, utilization management, Star Ratings, HEDIS, and value-based care performance metrics, with the ability to apply this knowledge to market-level performance improvement.

• Medical Necessity and Prior Authorization: Ability to apply evidence-based criteria, clinical guidelines, and CMS-compliant standards to complex authorization decisions across the non-acute continuum.

• Clinical and Operational Data Analysis: Ability to interpret complex clinical, financial, and quality performance data; identify root causes of performance variation; and translate findings into actionable, provider-facing improvement strategies.

• Provider Engagement and Relationship Management: Demonstrated experience working collaboratively with physicians, provider groups, delegated medical groups, and executive stakeholders to influence performance, drive operational change, and build sustainable clinical partnerships.

• Utilization Management and Medical Expense Analysis: Working knowledge of outpatient and non-acute utilization trends, site-of-service optimization, readmission drivers, referral patterns, and medical expense management, with the ability to lead corrective action planning in response to adverse trends.

• Quality and Star Ratings Improvement: Knowledge of HEDIS, CAHPS, HOS, and Star Ratings program requirements.

• Patient Safety and Risk Management: Knowledge of healthcare risk management frameworks and patient safety principles as applied to utilization decisions and care transitions.

• Communication and Executive Presentation: Excellent written, verbal, and presentation skills, with the ability to communicate complex clinical and financial findings clearly to providers, market leadership, and executive stakeholders.

• Cross-Functional Collaboration: Proven ability to operate in matrixed environments, partnering across utilization management, care management, quality, risk adjustment, analytics, and operational teams to drive aligned execution.

Preferred:

Licensure:

Required:

Preferred:

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $262,145.00 - $393,217.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

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