Medical Director, Utilization & Care Management

Highmark Health; Baton Rouge (LA); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. seeks a physician to join a dedicated team and lead utilization management activities in line with NCQA, URAC, CMS, and DOH standards. The role reviews escalated cases electronically and via policy criteria to determine medical necessity and appropriateness of services.

The physician will participate in multidisciplinary CMDM discussions, contribute to protocol development, and may work on special projects to improve member care. Telephonic peer-to-peer discussions may be required.

Qualifications

• MD or DO with active medical license.
• 5 years in clinical direct patient care.
• Board certification in ABMS or AOA.
• Preferred: MBA or MPH.

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.
• Attend huddles and grand rounds and contribute to protocol/guideline development.
• Lead or participate in physician-led project teams to improve care for members.
• Ensure compliance 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/MPH

Job description

Highmark Inc. seeks a physician to join a dedicated team and lead utilization management activities in line with NCQA, URAC, CMS, and DOH standards. The role reviews escalated cases electronically and via policy criteria to determine medical necessity and appropriateness of services.

The physician will participate in multidisciplinary CMDM discussions, contribute to protocol development, and may work on special projects to improve member care. Telephonic peer-to-peer discussions may be required.