Medical Director, Utilization & Care Management

Physician Pivot; On; On-site; EUR 203,000 - 344,000; Full time

Job summary

Highmark Inc. seeks a physician to join its utilization management team. The role ensures clinical standards are applied, reviews escalated cases, and participates in the multidisciplinary CMDM team to advise on high-risk cases.

Responsibilities include developing review protocols, guiding medical necessity decisions, and supporting projects related to patient care, while maintaining compliance with NCQA, URAC, CMS, DOH, and DOL regulations.

Qualifications

• MD or DO degree required.
• Board Certification in a specialty recognized by ABMS or AOA required.
• Active medical state licensure required.
• Preferred MBA or MPH.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Participate as a CMDM team member; attend huddles and grand rounds.
• Develop protocols and guidelines to ensure consistency in the review process.
• Actively manage projects or participate on project teams requiring physician expertise.
• Other duties as assigned.

Skills

Oral & Written

Critical Thinking

Case Management

Customer Service

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

MBA/MPH

Job description

Highmark Inc. seeks a physician to join its utilization management team. The role ensures clinical standards are applied, reviews escalated cases, and participates in the multidisciplinary CMDM team to advise on high-risk cases.

Responsibilities include developing review protocols, guiding medical necessity decisions, and supporting projects related to patient care, while maintaining compliance with NCQA, URAC, CMS, DOH, and DOL regulations.