Medical Director, Care Management & Utilization

Highmark Health; Annapolis (MD); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to join its utilization management team in Maryland. The role involves reviewing escalated cases electronically, applying Medical Policy criteria, and determining medical necessity for services.

You will participate in the CMDM multidisciplinary team, attend huddles and grand rounds, and advise on high-risk cases. The position emphasizes compliance with NCQA, URAC, CMS, DOH, and DOL standards.

Qualifications

• MD or DO required.
• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice).
• Active medical state licensure required; may require additional state licensure.
• Board certification by ABMS or AOA required.
• MBA/MPH preferred for advanced management knowledge.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds; advise on cases needing physician input.
• Contribute to protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects or participate on project teams requiring physician SME input.
• Other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

MBA/MPH (preferred)

Job description

Highmark Inc. is seeking a physician to join its utilization management team in Maryland. The role involves reviewing escalated cases electronically, applying Medical Policy criteria, and determining medical necessity for services.

You will participate in the CMDM multidisciplinary team, attend huddles and grand rounds, and advise on high-risk cases. The position emphasizes compliance with NCQA, URAC, CMS, DOH, and DOL standards.