Regional Medical Director, Non-Acute UM (San Antonio, El Paso, TX)

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 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.

Job Responsibilities:

Non-Acute Utilization Management Leadership. Lead physician oversight of market-level non-acute UM programs—including prior authorization, referral management, outpatient medical necessity determinations, DME, home health, advanced imaging, Part B medications, and site-of-service optimization—ensuring consistent application of CMS regulations, InterQual/MCG criteria, and evidence-based guidelines.

Provider Engagement and Utilization Performance. Partner with PCPs, specialists, hospitals, and delegated medical groups to improve utilization performance; conduct targeted physician education on referral appropriateness, site-of-service optimization, and procedural appropriateness; and meet regularly with contracted and delegated group medical directors to align referral patterns, prior authorization workflows, and medical management priorities.

Prior Authorization and Medical Necessity Oversight. Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient and non-acute requests; review authorization, denial, appeal, and overturn trends; support implementation of electronic prior authorization and automation initiatives; and reduce unnecessary care variation through provider education and compliance with clinical pathways. Partnering with UM operations to improve provider experience, authorization turnaround times, and first-pass approval rates. Ensuring medical decision-making incorporates member goals, prognosis, and informed consent principles. Facilitating timely transitions to lower levels of care when clinically appropriate.

Care Transitions and Post-Discharge Coordination. Ensure effective clinical handoffs between institutional and outpatient settings by coordinating with the Regional Medical Officer, Transition of Care, and Care Anywhere teams; establish prioritization of post-acute outreach based on member risk stratification; and monitor and address barriers contributing to avoidable readmissions, ED utilization, and gaps in care continuity. Supporting the acute UM team on post-discharge outpatient authorization needs, including DME, home health, follow-up imaging, and Part B infusions. Collaborating with providers and delegated groups to ensure post-acute plans align with member preferences, caregiver support, and community resources.

Ambulatory and Procedural Site-of-Service Optimization. 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 of service; and identify opportunities to reduce low-value care, unnecessary procedural variation, and avoidable inpatient or post-acute utilization.

Pharmacy and Specialty Medication Integration. Partner with Pharmacy leadership and the PBM on utilization management and optimization of Part B medications and infusion therapies; ensure members receiving specialty therapies have appropriate wraparound clinical support, monitoring, and care coordination; and engage aligned and delegated providers on Part B medication management in partnership with Network Management and Contracting.

Referral Management and Medical Management Coordination . Physician review of outpatient specialty referrals for medical necessity. Coordination of referral workflows with delegated groups aligned to benefit design. Partnering with delegated groups on shared medical management, referral trending, over/under-utilization, and network leakage. Peer-to-peer discussions with referring and consulting physicians to resolve referral disputes. Collaboration with Network Management to promote in-network referrals to preferred, high-value specialists.

Skilled Nursing Facility (SNF) Management-Acute Overflow Only. Physician leadership for post-acute care strategy and SNF utilization management. Discharge planning beginning on day of admission. Length-of-stay management and community transition support. Monitoring SNF LOS, readmission rates, discharge disposition, appeal rates, and member outcomes. Peer-to-peer reviews for direct-to-SNF admissions and complex placements. Developing preferred SNF networks and post-acute provider partnerships.

Preoperative Assessment and Surgical Readiness. Serve as the clinical lead for preoperative optimization within assigned markets by identifying members scheduled for elective procedures who need medical optimization; coordinating cardiovascular, pulmonary, diabetes, anticoagulation, frailty, and nutritional assessments with surgeons, specialists, PCPs, and pharmacists; and reducing preventable surgical complications, readmissions, and unnecessary post-acute utilization through comprehensive preoperative planning.

Performance Analytics and Improvement. Monitor and act on KPIs including MLR, authorization volume, approval/denial/appeal/overturn rates, referral volume and in-network capture rate, ED visits per thousand, ASC and outpatient surgical utilization, non-institutional costs, and Star Ratings measures including Plan All-Cause Readmissions (PCR); and partner with analytics and operational leaders to evaluate program effectiveness and drive continuous improvement.

Regulatory, Compliance, and Quality Oversight. Ensure all clinical decisions comply with CMS, NCQA, and applicable state regulatory requirements; participate in audits, appeals, grievance reviews, and regulatory inquiries; and support quality improvement initiatives that improve patient safety, outcomes, and member experience.

Acute UM Overflow — As Directed and Approved. When explicitly assigned acute UM overflow duties by the UM team and approved by the CDO, perform 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 using acute UM criteria and escalation pathways; these are not standing responsibilities of the RMD Non-Acute UM.

Other duties, tasks, projects and responsibilities may be assigned as needed.

Supervisory Responsibilities:

This role is an individual contributor role with no supervisory responsibilities.

Required Travel

This is a local-market position requiring a combination of remote work, home-b