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.

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, Inter Qual/MCG criteria, and evidence-based guidelines.

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.

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.

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…