Medical Director, Utilization Management

🕒 May 1

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

👥 B2C

💰 $321.1M Post-IPO Debt - Alignment Health on 2024-11

Healthcare Insurance • B2C

Alignment Health is a Medicare-focused health insurance company that offers Medicare Advantage plans and member-centered services. It provides 24/7 on-demand access to care via in-person, in-home, and mobile channels and features a concierge-style on-demand card to help members schedule appointments, arrange transportation, and answer health questions. Alignment Health partners with brokers, providers, Accountable Care Organizations (ACOs), and institutional partners, operates in multiple U. S. states (including Arizona, California, Nevada, North Carolina, and Texas), and has earned high CMS ratings and industry recognition.

📋 Description

• Reports to the Senior VP of Clinical Operations with accountably to Chief Financial Officer and Chief Medical Officer. • Work with UM licensed staff, Regional Medical Officers and Extensivists to develop and implement methods to optimize use of Institutional and Outpatient services for all patients. • Complete clinical reviews for medical necessity, treatment appropriateness and compliance. • Second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy. • Provide appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines. • Act as a liaison between the medical staff, utilization review and third-party payers to effectively promote the appropriate levels of medical care.

🎯 Requirements

• 3-5 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required. • 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. • Excellent communication skills. • Great attention to detail as well as taking pride in being a good team member and communicate effectively with medical staff.

🏖️ Benefits

• Health insurance • Flexible schedule