Medical Director, Utilization Management

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The UM Medical Director/ Physician Advisor (UM MD/PA) reports to the Senior VP of Clinical Operations with accountably to Chief Financial Officer and Chief Medical Officer. The UM Medical Director/Physician Advisor works with UM licensed staff, Regional Medical Officers and Extensivists to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided. Through remote access to our web-based Portal, UM Medical Director/Physician Advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance.

GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO):

• Second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
• Provide appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
• Act as a liaison between the medical staff, utilization review and third-party payers to effectively promote the appropriate levels of medical care.
• Review the entire claim denial process, including pending claims, Appeals and Grievances.
• Serve as a Physician member of the utilization review team.
• Ensure appropriate service utilization by monitoring over- and underutilization
• Work with Interdisciplinary Team to develop AHC Utilization Management protocols, including auto-approvals and market specific protocols.
• Develop training material and assisting UM Manager to conduct Physicians' annual Interrater reliability testing
• Serve as a Subject Mater Expert (CME) to Regional Medical Officers and/or Extensivists during concurrent reviews.
• Serve as a Chairperson for Medical Quality Committee and provide Clinical Oversight of Quality Outcomes.
• Collaborates closely and assist Quality Director.
• Work with Provider Relation, Network Management and local Regional Medical Officers to ensure community Physician education on UM processes and regulations
• Assist the organization to challenge physician practices in order to achieve the organization's clinical outcomes and collaborates closely and assists Quality Director

SUPERVISORY RESPONSIBILITIES: UM Clinical Staff Oversight

MINIMUM REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum Experience:

Required: 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.

Preferred: Experience as a Physician Advisor

Education/Licensure:

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.

Preferred: Subspecialty or other post-residency fellowship.

Specialized Skills:

• 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.
• Dedication to the delivery of high-quality, cost-effective, efficient patient care services
• Excellent communication skills
• Great attention to detail as well as taking pride in being a good team member and communicate effectively with medical staff.
• Mon- Fri 8- 5PM with some weekend requirements.
• Flexible schedule

ESSENTIAL PHYSICAL FUNCTIONS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear.

2. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

3. The employee frequently lifts and/or moves up to 10 pounds.

4. Specific vision abilities required by this job include close vision and the ability to adjust focus

Pay Range:

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

• DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com.