Utilization Management Assistant Jobs in Durham, NC

The Physical Health Medical Director plays a key role within the Physical Health Medical Management Team, providing clinical oversight, medical expertise, and operational support for physical health services. This position ensures high quality, evidence based medical review processes and supports organizational goals related to clinical quality, utilization management, and care coordination.

This position will allow the successful candidate to work primarily remote. While there is no expectation to be in the office routinely, the selected candidate may be required to report on-site as needed. It's strongly preferred that the selected candidate reside in North Carolina or be willing to relocate. This position may be required to work weekends and holidays based on organizational and operational requirements.

Responsibilities & Duties

Clinical Oversight & Medical Review

• Provide expert guidance and oversight for physical health service requests, including authorization of services and determination of appropriate level of care
• Ensure the integrity and quality of utilization management activities, including initial reviews, concurrent reviews, appeals, and level of care determinations for inpatient and outpatient services
• Participate in internal reviews of inpatient and outpatient clinical case types to ensure compliance with regulatory, accreditation, and organizational standards

Review Approval and Denial of Service and Level of Care Requests

• Apply medical necessity criteria utilizing review criteria hierarchy for level of care and services regarding type, amount, and duration of service. Complete expected case volume as expected by the department

Process Adherence, Quality & Efficiency

• Follow department processes—as defined by approved Alliance policies, desk procedures, and workflows referenced on the Alliance Grid and in the Medical Director OneNote—to complete timely utilization reviews in Alliance’s UM platform and perform tasks efficiently
• Apply established workflows and maintain quality case reviews to ensure consistent decision making, documentation accuracy, and adherence to regulatory compliance

Operational & Committee Support

• Support the Clinical Operations Department through active participation in organizational committees, including but not limited to Clinical Quality Review, Transition of Care Rounds, Overturn Committee
• Provide clinical guidance and leadership to promote collaboration between medical, behavioral, and care management teams

External Engagement

• Participate in mediation activities and Office of Administrative Hearing (OAH) processes as required, providing clinical expertise and documentation support

Additional Responsibilities

• Maintain awareness of regulatory requirements, utilization management guidelines, and emerging trends affecting utilization management and physical health services
• Contribute to process improvement initiatives aimed at enhancing clinical quality, efficiency, and member outcomes
• Support cross functional teams with medical expertise, as needed
• Provide consultation, training, and education to staff and community partners on relevant topics as needed
• Train and mentor peers within the Medical Management team and assist with onboarding PH Medical Director new hires as needed

Maintain a Positive Environment

• Work with Human Resources and Medical Team to attract, maintain, and retain a highly qualified and well-trained workforce
• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust with teammates
• Ensure all staff are treated with respect and dignity
• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members

Minimum Requirements

Education & Experience

Graduation from an accredited Medical School. M.D./D.O. degree is required and board certification in a relevant field. At least four (4) years of postgraduate clinical experience and two (2) or more years of managed care and utilization management experience are required.

Special Requirement

Current, active, and unrestricted license to practice medicine in North Carolina or meets qualifications to obtain a North Carolina Medical License with Board certification for appropriate field of Medicine (American Board of Family Medicine or American Board of Internal Medicine).

Knowledge, Skills, & Abilities

• Knowledge of the information and techniques needed for diagnosis and treatment of medical issues, including symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures
• Knowledge of Managed Care Principles
• Knowledge of recent developments in the field of medicine
• Microsoft Office Skills
• Ability to speak with colleagues about treatment concerns, complex case issues and best practice recommendations
• Utilization Management experience

Salary Range

$211,172 - $269,245/Annually 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity

 An excellent fringe benefit package accompanies the salary, which includes:  

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility