Medical Director, Utilization & Care Management

Highmark Health; Dover; On-site; GBP 170,000 - 288,000; Full time

Job summary

Highmark Inc. is seeking a physician reviewer to ensure utilization management duties meet current clinical standards.

You will review escalated cases electronically and, when needed, via telephonic peer discussions, applying Medical Policy criteria to assess medical necessity and appropriateness. As a member of the CMDM multidisciplinary team, you will advise on high‑risk cases, participate in protocol development, and support special projects while adhering to NCQA, URAC, CMS, DOH, and DOL

Qualifications

• MD or DO required.
• 5 years in clinical direct patient care.
• Board Certification in specialty recognized by ABMS or AOa.
• Active medical state licensure required.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria; may include telephonic peer discussions.
• Review appeals and grievances; draft clear rationales for notifications.
• Participate in CMDM multidisciplinary team; attend huddles and grand rounds; advise on cases needing physician expertise.
• Develop protocols and guidelines to ensure consistency in review processes.
• Manage projects or join project teams requiring physician SME.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

MBA or MPH (Preferred)

Job description

Highmark Inc. is seeking a physician reviewer to ensure utilization management duties meet current clinical standards.

You will review escalated cases electronically and, when needed, via telephonic peer discussions, applying Medical Policy criteria to assess medical necessity and appropriateness. As a member of the CMDM multidisciplinary team, you will advise on high‑risk cases, participate in protocol development, and support special projects while adhering to NCQA, URAC, CMS, DOH, and DOL