Remote Regional Medical Director, Non-Acute UM (Must reside in NC)

Alignment Healthcare•Carolina, NC

2d•Remote

About The Position

The Remote Regional Medical Director, Non-Acute Utilization Management (RMD Non-Acute UM) is a market-facing physician leader responsible for optimizing clinical outcomes, quality performance, utilization management, and total cost of care through non-acute clinical programs across assigned provider networks and markets. The role partners closely with the Regional Medical Officer and serves as the primary physician leader for Prior Authorization, Referral Management, Utilization Management, Clinical Operations, Care Anywhere (CAW), Case Management, Pharmacy, Network Management, and Quality. The RMD Non-Acute UM works directly with contracted network providers, delegated medical groups, and de-delegated non-acute functions to advance MLR, Star Ratings, member experience, and value-based care performance. Key outcomes include appropriate resource utilization, reduced avoidable post-acute placement, improved in-network referral capture, and measurable improvement in non-acute cost and quality performance. The position must be based in North Carolina and combines remote work, home-based clinical visits, and regular in-person collaboration, with routine travel throughout assigned local markets and occasional travel to the corporate office and organizational events. This is an individual contributor role with no supervisory responsibilities.

Requirements

Minimum five to ten years of Utilization Management clinical practice experience.
Minimum three years of leadership experience within managed care, Medicare Advantage, physician organizations, IPA/MSO, or value-based care environments.
MD or DO degree from an accredited institution.
Board certification in an ABMS- or AOA-recognized specialty.
Active, unrestricted medical license in North Carolina.
Demonstrated working knowledge of Medicare Advantage operations, managed care principles, and CMS regulatory requirements applicable to utilization management, quality, and population health.
Comprehensive knowledge of Medicare Advantage and managed care operations, utilization management, Star Ratings, HEDIS, and value-based care performance metrics, and ability to apply this knowledge to market-level improvement.
Ability to apply evidence-based criteria, clinical guidelines, and CMS-compliant standards to complex authorization decisions across the non-acute continuum.
Ability to interpret clinical, financial, and quality performance data, identify root causes of performance variation, and translate findings into actionable provider-facing improvement strategies.
Experience collaborating with physicians, provider groups, delegated medical groups, and executive stakeholders to influence performance, drive operational change, and build clinical partnerships.
Working knowledge of outpatient and non-acute utilization trends, site-of-service optimization, readmission drivers, referral patterns, and medical expense management, including corrective action planning.
Knowledge of HEDIS, CAHPS, HOS, and Star Ratings program requirements.
Knowledge of healthcare risk management frameworks and patient safety principles as applied to utilization decisions and care transitions.
Excellent written, verbal, and presentation skills, including the ability to communicate complex clinical and financial findings to providers, market leadership, and executive stakeholders.
Ability to work effectively in matrixed environments and collaborate across utilization management, care management, quality, risk adjustment, analytics, and operational teams.
Ability to work independently and collaboratively across geographically dispersed teams while maintaining local-market engagement and accountability.
Ability to meet the stated physical demands, with reasonable accommodations available as described in the posting.

Nice To Haves

Experience supporting delegated provider groups, IPAs, ACOs, or risk-bearing entities, including direct medical management engagement with delegated group medical directors and physician leaders.
Prior leadership experience supporting Medicare Star Ratings improvement initiatives.
Familiarity with clinical analytics, utilization trending, and provider scorecard methodologies.
Experience with outpatient prior authorization and referral management workflows.
Board certification in Family Medicine or Internal Medicine.
Ambulatory or outpatient practice experience; hospitalist or SNF experience is helpful for acute overflow assignments.
Formal training in quality improvement methodologies, population health management, or managed care operations.
Familiarity with HEDIS, Star Ratings, risk adjustment, and value-based care performance frameworks.

Responsibilities

Lead physician oversight of market-level non-acute utilization management programs, including prior authorization, referral management, outpatient medical necessity determinations, DME, home health, advanced imaging, Part B medications, and site-of-service optimization, applying CMS regulations, InterQual/MCG criteria, and evidence-based guidelines.
Partner with PCPs, specialists, hospitals, and delegated medical groups to improve utilization performance; provide physician education; and meet with contracted and delegated group medical directors to align referral patterns, prior authorization workflows, and medical management priorities.
Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient and non-acute requests; review authorization, denial, appeal, and overturn trends; support electronic prior authorization and automation; and reduce unnecessary care variation through provider education and clinical pathways.
Partner with UM operations to improve provider experience, authorization turnaround times, and first-pass approval rates; ensure medical decisions account for member goals, prognosis, and informed consent; and facilitate timely transitions to lower levels of care when appropriate.
Coordinate clinical handoffs between institutional and outpatient settings with the Regional Medical Officer, Transition of Care, and Care Anywhere teams; prioritize post-acute outreach based on member risk; and address barriers contributing to avoidable readmissions, ED utilization, and gaps in care continuity.
Support the acute UM team on post-discharge outpatient authorization needs, including DME, home health, follow-up imaging, and Part B infusions; collaborate with providers and delegated groups to align post-acute plans with member preferences, caregiver support, and community resources.
Lead physician strategy for preferred Ambulatory Surgery Center utilization and procedural appropriateness; collaborate with specialists, delegated medical groups, Network Management, and Contracting to increase use of high-quality, cost-effective sites and reduce low-value care and avoidable utilization.
Partner with Pharmacy leadership and the PBM on management and optimization of Part B medications and infusion therapies; ensure appropriate clinical support, monitoring, and care coordination for specialty therapies; and engage aligned and delegated providers on Part B medication management.
Review outpatient specialty referrals for medical necessity; coordinate referral workflows with delegated groups and benefit design; collaborate on shared medical management and utilization trends; resolve referral disputes through peer-to-peer discussions; and promote in-network referrals to preferred, high-value specialists.
Provide physician leadership for post-acute care strategy and SNF utilization management for acute overflow only, including discharge planning, length-of-stay management, community transition support, monitoring SNF outcomes, peer-to-peer reviews for direct-to-SNF admissions and complex placements, and development of preferred SNF networks and partnerships.
Lead preoperative optimization for members scheduled for elective procedures by coordinating relevant medical assessments with surgeons, specialists, PCPs, and pharmacists, and reducing preventable surgical complications, readmissions, and unnecessary post-acute utilization.
Monitor and act on performance indicators including MLR, authorization volume and outcomes, referral volume and in-network capture, ED visits, ASC and outpatient surgical utilization, non-institutional costs, and Star Ratings measures including Plan All-Cause Readmissions (PCR). Partner with analytics and operational leaders to evaluate programs and drive improvement.
Ensure clinical decisions comply with CMS, NCQA, and applicable state requirements; participate in audits, appeals, grievance reviews, and regulatory inquiries; and support quality improvement initiatives related to patient safety, outcomes, and member experience.
Perform acute UM overflow duties only when explicitly assigned by the UM team and approved by the CDO, including SNF concurrent review, peer-to-peer consultations, and length-of-stay determinations for acute admissions, direct-to-SNF placements, LTAC admissions, acute rehabilitation, and tertiary transfers.
Perform other duties, tasks, projects, and responsibilities as assigned.
Maintain a visible presence in assigned local markets and regularly engage with CAW, TOC, Clinical Operations, UM, Network partners, direct network providers, and delegated medical group leadership; travel locally for patient visits, physician meetings, joint operating committees, operational initiatives, and relationship management.