Medical Director, Care Quality & Utilization

Highmark Health; Richmond (VA); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. in the United States is seeking a physician to perform utilization management as part of a multidisciplinary team.

You will review escalated cases electronically, discuss with peers as needed, and ensure adherence to current clinical standards and regulatory requirements. The role involves participating in case/disease management, advising on high-risk cases, and may include special projects to improve member care.

Qualifications

• MD or DO medical degree is required.
• Active medical state licensure required; board certification in a relevant specialty is expected.
• Board certification by ABMS/AOA is required.
• Preferred MBA or MPH.
• 5 years in clinical direct patient care is required.

Responsibilities

• Conduct electronic reviews of escalated cases against medical policy to determine medical necessity and appropriateness.
• Participate as a CMDM team member; attend huddles and rounds and advise on cases needing physician input.
• Contribute to protocol and guideline development to ensure consistency in review.
• Lead or participate in physician-led projects related to medical management and care coordination.
• Comply with NCQA, URAC, CMS, DOH, and DOL regulations in all activities.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Master’s in Business Administration/Management or Public Health

Job description

Highmark Inc. in the United States is seeking a physician to perform utilization management as part of a multidisciplinary team.

You will review escalated cases electronically, discuss with peers as needed, and ensure adherence to current clinical standards and regulatory requirements. The role involves participating in case/disease management, advising on high-risk cases, and may include special projects to improve member care.