Medical Director – Utilization Management
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Job Description
Medical Director optimizing utilization management and clinical quality for Alignment Health’s senior-focused healthcare services. Conducting remote medical-necessity reviews and overseeing UM clinical staff.
Responsibilities:
- Report to the Senior VP of Clinical Operations, with accountability to the Chief Financial Officer and Chief Medical Officer
- Work with UM licensed staff, Regional Medical Officers, and Extensivists to optimize use of institutional and outpatient services while ensuring quality of care
- Complete remote clinical reviews through the web-based Portal for medical necessity, treatment appropriateness, and compliance
- Conduct second-level reviews under Medicare/CMS NCD, LCD, and Milliman guidelines for inpatient, outpatient, skilled-facility level of care, and pharmacy services
- Provide level-of-care classifications and continued-stay reviews
- Liaise among medical staff, utilization review teams, and third-party payers
- Review claim denials, pending claims, appeals, and grievances
- Serve as a physician member of the utilization review team
- Monitor overutilization and underutilization
- Develop utilization management protocols, including auto-approvals and market-specific protocols, with the Interdisciplinary Team
- Develop training materials and assist with physicians' annual interrater reliability testing
- Serve as a subject matter expert to Regional Medical Officers and/or Extensivists during concurrent reviews
- Chair the Medical Quality Committee and provide clinical oversight of quality outcomes
- Collaborate with and assist the Quality Director
- Educate community physicians on utilization management processes and regulations with Provider Relations, Network Management, and Regional Medical Officers
- Challenge physician practices to achieve organizational clinical outcomes
- Provide oversight of UM clinical staff
Requirements:
- 3-5 years of experience in a hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance
- Completion of medical school and specialty residency, preferably in internal medicine
- Board Certification
- Current, non-restricted licensure as required for clinical practice in the State or US territory in which medical decisions are being made
- Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations
- Ability to build rapport with medical staff and management leadership to obtain approvals of utilization management strategies
- Excellent communication skills and attention to detail
- Availability Monday-Friday, 8 AM-5 PM, with some weekend requirements
Benefits:
- Fully remote work arrangement
- Flexible schedule
- Opportunity for growth and innovation
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