Medical Director – Utilization Management

Alignment Health

Medical Director overseeing utilization management for Alignment Health. Collaborating with licensed staff to ensure quality of care and compliance across services including inpatient and outpatient.

Posted 5/1/2026full-timeRemote • 🇺🇸 United StatesLeadWebsite

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

Health insurance
Paid time off
Flexible schedule

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical reviewsmedical necessitytreatment appropriatenesscompliancelevel of care classificationscontinued stay reviewsutilization managementcase managementquality managementmedical decision making

Soft Skills

communication skillsrapport buildingleadershipcollaborationliaison

Certifications

Board Certificationmedical school completionspecialty residency