Medical Director – Utilization Management

🕒 May 1

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• Reports to the Senior VP of Clinical Operations with accountability to Chief Financial Officer and Chief Medical Officer. • Works with UM licensed staff, Regional Medical Officers and Extensivists to develop methods to optimize use of Institutional and Outpatient services for all patients while ensuring quality of care. • Completes clinical reviews for medical necessity, treatment appropriateness, and compliance through remote access to web-based Portal. • Second level reviews in compliance with Medicare/CMS guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy. • Provides appropriate level of care classifications and continued stay reviews. • Act as a liaison between medical staff, utilization review, and third-party payers. • Reviews the entire claim denial process, including pending claims, Appeals, and Grievances. • Serves as a Physician member of the utilization review team.

🎯 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. • Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management. • Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations. • Excellent communication skills.

🏖️ Benefits

• Health insurance • Paid time off • Flexible schedule