Medical Director, Care & Utilization Management

Highmark Health; Montpelier (VT); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. seeks a physician expert to join a multidisciplinary team focused on utilization management. You will review escalated cases electronically, determine medical necessity, and discuss with peers when needed, ensuring compliance with NCQA, URAC, CMS, DOH, and DOL standards.

You will participate in CMDM rounds, contribute to protocol development, and lead or join projects that improve member care. MD/DO, board certification, and 5 years of clinical experience are required.

Qualifications

• MD or DO with active state licensure and board certification.
• At least 5 years of clinical or direct patient care experience.
• Experience in medical management or managed care is preferred.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Determine medical necessity and appropriateness; document rationales clearly.
• Participate in CMDM multidisciplinary team and advise on complex cases.
• Contribute to protocol and guidelines development and lead projects as needed.
• Comply with NCQA, URAC, CMS, DOH, and DOL regulations.

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 or MPH (preferred)

Tools

Clinical Software

Job description

Highmark Inc. seeks a physician expert to join a multidisciplinary team focused on utilization management. You will review escalated cases electronically, determine medical necessity, and discuss with peers when needed, ensuring compliance with NCQA, URAC, CMS, DOH, and DOL standards.

You will participate in CMDM rounds, contribute to protocol development, and lead or join projects that improve member care. MD/DO, board certification, and 5 years of clinical experience are required.