Medical Director

Highmark health; United States; On-site; USD 227,600 - 385,000; Full time

Job summary

Highmark Health is seeking a physician to join a multidisciplinary team focused on utilization management. Responsibilities include electronic case reviews against medical policy criteria and peer-to-peer discussions to determine medical necessity, while ensuring compliance with NCQA, URAC, CMS, DOH, and DOL standards.

The role also involves participating in disease management discussions, protocol development, and leading physician-led projects.

Qualifications

• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice).
• Board certification in a specialty recognized by ABMS or ABOCSA.
• Active medical state licensure required; additional state licenses may be required.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds.
• Advise multidisciplinary team on cases requiring physician expertise.
• Develop protocols and guidelines to ensure consistency in the review process.
• Manage projects and participate on teams requiring physician SME.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Job description

JOB SUMMARY

This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high‑risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.

ESSENTIAL RESPONSIBILITIES

• Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that all aspects of the medical management process are consistent with community standards of care.
• Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
• Participate in protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician subject matter expert.
• Other duties as assigned.

EDUCATION

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

EXPERIENCE

• Required: 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
• Preferred: 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

LICENSES AND CERTIFICATION

• Required:
  • Medical Doctor or Doctor of Osteopathic Medicine (DO)
  • Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
  • Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.
• Preferred: None

SKILLS

• Critical Thinking
• Case Management
• Customer Service
• Oral & Written Communication Skills
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type: Office-Based

Teaches / trains others regularly: Occasionally

Travel regularly from the office to various work sites or from site-to-site: Rarely

Works primarily out‑the‑office selling products/services (sales employees): Never

Physical work site required: No

Lifting up to 10 pounds: Constantly

Lifting 10 to 25 pounds: Rarely

Lifting 25 to 50 pounds: Rarely

Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

PAY RANGE

• Minimum: $227,600.00
• Maximum: $385,000.00

EEO STATEMENT

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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