Medical Director, Care & Utilization Management

Highmark Health; Springfield (IL); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to oversee utilization management within a physician team, evaluating medical necessity and medical policy adherence for services. The role includes peer-to-peer discussions, regulatory compliance, and clinical collaboration within a multidisciplinary group.

The position emphasizes participation in disease management, protocol development, and project work to improve care for members. Board certification and active licensure support eligibility.

Qualifications

• MD or DO required; Board certification as recognized by ABMS or AOA preferred.
• Active medical state licensure required; some state licensure may be needed based on business needs.
• Master's in Business Administration or Public Health preferred.

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 complex cases.
• Assist in protocol and guidelines development to ensure consistency in review.
• Lead or participate in projects requiring physician subject matter expertise.
• 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 or DO

Job description

Highmark Inc. is seeking a physician to oversee utilization management within a physician team, evaluating medical necessity and medical policy adherence for services. The role includes peer-to-peer discussions, regulatory compliance, and clinical collaboration within a multidisciplinary group.

The position emphasizes participation in disease management, protocol development, and project work to improve care for members. Board certification and active licensure support eligibility.