Medical Director - Care & Utilization Management

Highmark Health; Helena (MT); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to join a dedicated team focused on utilization management. The role reviews escalated cases using Medical Policy criteria to determine medical necessity, sometimes via telephonic peer discussions, while ensuring NCQA, URAC, CMS, DOH, and DOL compliance.

As a CMDM participant, you will advise on high-risk cases within a multidisciplinary team and may contribute to protocol development and special projects to improve member care. MD or DO required.

Qualifications

• MD or DO is required.
• 1 year of medical management in health insurance preferred.
• Active medical state licensure required; board certification in appropriate specialty preferred.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity.
• Participate as a CMDM multidisciplinary team member and advise on high-risk cases.
• Develop protocols and guidelines to ensure consistency in review processes.
• Lead or participate in physician-led projects to support member care.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD or DO

MBA/MPH (preferred)

Job description

Highmark Inc. is seeking a physician to join a dedicated team focused on utilization management. The role reviews escalated cases using Medical Policy criteria to determine medical necessity, sometimes via telephonic peer discussions, while ensuring NCQA, URAC, CMS, DOH, and DOL compliance.

As a CMDM participant, you will advise on high-risk cases within a multidisciplinary team and may contribute to protocol development and special projects to improve member care. MD or DO required.