Medical Director – Utilization Management

Alignment Health

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.

Posted 9/4/2026full-timeRemote • 🇺🇸 United StatesLead💰 $262,145 - $393,217 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management, Clinical Oversight, and Quality Management, with a strong focus on compliance and healthcare delivery systems. Proven ability to collaborate with medical staff and leadership to optimize clinical outcomes and develop effective utilization protocols.

Highest-signal resume keywords

Utilization ManagementClinical OversightQuality ManagementBoard CertificationMedical Necessity Review

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical CareQuality ManagementUtilization ManagementCase ManagementMedical Staff GovernanceLevel-of-Care ClassificationClinical ReviewCompliance MonitoringTraining DevelopmentHealthcare Financial Issues

Soft Skills

Excellent CommunicationAttention to DetailRapport Building

Tools & Technologies

Web-Based Portal

Certifications & Qualifications

Board CertificationCurrent Licensure

Industry Keywords

MedicareCMS NCDLCDMilliman GuidelinesInterdisciplinary TeamQuality OutcomesProvider RelationsNetwork Management

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

Fully remote work arrangement
Flexible schedule
Opportunity for growth and innovation