Medical Director — Clinical Care & Utilization Management

Highmark Health; Topeka (KS); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health seeks a physician to support utilization management within a multidisciplinary team. You will review escalated cases electronically, discuss cases by phone when needed, and ensure adherence to policy criteria and regulatory standards.

Qualifications include MD/DO, 5+ years clinical experience, active state licensure and board certification. The role involves analytics, project work, and collaboration across care teams in a dynamic health plan setting.

Qualifications

• MD/DO degree required.
• 5 years in clinical direct patient care.
• Active medical state licensure required with board certification.
• Board certification in a specialty recognized by ABMS or AOA.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate as a CMDM multidisciplinary team member and advise on high-risk cases.
• Contribute to protocol/guidelines development to ensure review process consistency.
• Lead or participate in physician-led projects within medical management.
• Other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Master's Degree in Business Administration/Management or Public Health

Job description

Highmark Health seeks a physician to support utilization management within a multidisciplinary team. You will review escalated cases electronically, discuss cases by phone when needed, and ensure adherence to policy criteria and regulatory standards.

Qualifications include MD/DO, 5+ years clinical experience, active state licensure and board certification. The role involves analytics, project work, and collaboration across care teams in a dynamic health plan setting.