Medical Director, Utilization & Care Management

Highmark Health; Atlanta (GA); On-site; USD 29,000 - 35,000; Full time

Job summary

Highmark Health seeks a physician to perform utilization management reviews in alignment with clinical standards. You will review escalated cases, engage in peer-to-peer discussions when needed, and ensure compliance with NCQA, URAC, CMS, DOH, and DOL regulations.

You will contribute to disease management as part of a multidisciplinary team, advise on high‑risk cases, and may lead special projects to improve member care. Travel up to 25% may be required.

Qualifications

• MD or DO with active state licensure.
• Board certification in a related specialty.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Participate as a physician member of the CMDM team and advise on high-risk cases.
• Develop protocols/guidelines to standardize reviews and participate in special projects.

Education

MD/DO

Board Certification

Active medical state license

Job description

Highmark Health seeks a physician to perform utilization management reviews in alignment with clinical standards. You will review escalated cases, engage in peer-to-peer discussions when needed, and ensure compliance with NCQA, URAC, CMS, DOH, and DOL regulations.

You will contribute to disease management as part of a multidisciplinary team, advise on high‑risk cases, and may lead special projects to improve member care. Travel up to 25% may be required.