Medical Director, Care & Utilization Management

Highmark Health; Juneau (AK); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to join a team delivering utilization management in line with NCQA, URAC, CMS and state requirements.

You will review escalated cases electronically, discuss with peers, and determine medical necessity and appropriateness of proposed treatments. As a CMDM team member, you will participate in rounds, advise on high-risk cases, and help develop protocols to ensure consistent reviews.

Qualifications

• MD or DO required; board certification in a relevant specialty.
• Active medical license; state-specific requirements may apply.
• Preferred MBA or MPH in public health or management.
• Minimum 5 years in direct clinical care; managed care knowledge a plus.

Responsibilities

• Review escalated cases against medical policy criteria to determine necessity and appropriateness.
• Participate as a CMDM team member; attend rounds and advise on high-risk cases.
• Develop and refine review protocols to ensure consistent, compliant decisions.
• Lead or participate in projects requiring physician subject matter expertise.
• Perform other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

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 a team delivering utilization management in line with NCQA, URAC, CMS and state requirements.

You will review escalated cases electronically, discuss with peers, and determine medical necessity and appropriateness of proposed treatments. As a CMDM team member, you will participate in rounds, advise on high-risk cases, and help develop protocols to ensure consistent reviews.