Regional Medical Director, Non-Acute UM (Fresno, CA)
Core
Physician leader optimizing clinical outcomes, utilization management, and total cost of care through non-acute clinical programs across provider networks.
Role type
Senior physician leader (non-acute utilization management)
Builds
Non-acute clinical programs, prior authorization workflows, referral management systems, and post-acute care coordination strategies
Domain
Healthcare administration, utilization management, non-acute care
Required skills
Utilization management, prior authorization review, referral management, post-acute care coordination, site-of-service optimization, pharmacy management, regulatory compliance, performance analytics, peer-to-peer consultation, discharge planning
Preferred skills
Experience with CMS regulations, InterQual/MCG criteria, electronic prior authorization systems, value-based care models
Technologies
Electronic prior authorization systems, analytics platforms, care management software
Responsibilities
Lead physician oversight of market-level non-acute UM programs including prior authorization and referral management; Partner with providers to improve utilization performance and reduce avoidable post-acute placement; Conduct peer-to-peer consultations and medical necessity reviews for complex outpatient requests; Coordinate clinical handoffs between institutional and outpatient settings; Lead physician strategy for ambulatory surgery center utilization and procedural appropriateness; Partner with pharmacy leadership on utilization management of Part B medications; Review outpatient specialty referrals for medical necessity; Provide physician leadership for post-acute care strategy and SNF utilization management; Serve as clinical lead for preoperative optimization within assigned markets; Monitor and act on KPIs including MLR, authorization rates, and Star Ratings measures; Ensure all clinical decisions comply with CMS, NCQA, and applicable state regulatory requirements
Seniority
Senior, hands-on IC