Medical Director – Utilization Management

🔥 25 minutes ago

🇺🇸 United States – Remote

💵 $262.1k - $393.2k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $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

• 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