Medical Director, Utilization Management

Job not on LinkedIn

🔥 16 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $186k - $223.2k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

👻 Ghost score 0%

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Altais

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2019

🏥 Healthcare

👥 B2C

🧘 Wellness

Healthcare • B2C • Wellness

Altais is a California-based healthcare provider network that unifies multiple medical brands to offer coordinated primary care, urgent care, specialty services, hospitals and labs, and mental and senior health across Northern and Southern California. The organization supports physicians and care teams with technology-enabled patient portals and value-based care partnerships, serving patients directly while also working with providers and partners to improve access, affordability, and care coordination.

📋 Description

• Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services • Develop and implement clinical protocols, guidelines, and standards • Monitor and evaluate clinical performance metrics and outcomes • Lead quality improvement initiatives to enhance patient care and safety • Oversee evidence-based practices and clinical pathways • Review clinical data to identify areas for improvement • Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics • Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions • Foster relationships with network physicians and healthcare providers • Address clinical issues, improve care coordination, and promote best practices with providers • Facilitate provider education and training programs • Provide physician leadership for utilization management activities • Participate in prospective, concurrent, and retrospective utilization reviews, including medical necessity determinations, treatment plans, hospital admissions, and specialty referrals • Serve as a clinical resource for complex utilization, authorization, and care management cases • Develop, implement, and refine utilization management policies, procedures, clinical criteria, and authorization guidelines • Analyze utilization trends, referral patterns, inpatient and outpatient utilization data, and care coordination opportunities • Participate in appeals and peer-to-peer discussions with health plans and providers • Provide clinical oversight related to high-risk patient management, transitions of care, and complex case reviews • Participate in and/or chair Utilization Management Committee meetings • Present utilization trends, performance metrics, and improvement opportunities to leadership • Ensure compliance with regulatory requirements and industry standards • Manage audits and accreditation processes • Contribute to the IPA's strategic plan and identify growth opportunities • Participate in network expansion, provider recruitment, retention, interviews, onboarding, and orientation • Serve as AMG Friendly Physician for the Southern California Region

🎯 Requirements

• MD or DO degree from an accredited medical school • Active and unrestricted medical license • Minimum of 5 years of clinical experience, with at least 3 years in a leadership role • Board certification in a medical specialty • Strong understanding of quality improvement methodologies and healthcare regulations • Excellent communication, leadership, and interpersonal skills • Ability to analyze complex clinical data and develop actionable insights • Strong knowledge of utilization management, care management, population health, and value-based care principles • Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines • Experience managing provider appeals, authorization reviews, and payer interactions • Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics • Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement • Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment strongly preferred • Prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs preferred • Experience working with delegated managed care arrangements, health plan partners, and utilization management committees preferred • External hires must pass a background check/drug screen

🏖️ Benefits

• Excellent medical, vision, and dental coverage • 401k savings plan with a company match • Flexible time off • 9 Paid Holidays • Eligibility to participate in the annual bonus program