Medical Director, Utilization & Care Management

Highmark Health; Charleston (WV); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. in Charleston, WV seeks an experienced physician to join a utilization management team. You will review escalated cases, determine medical necessity, and engage in peer discussions as needed.

The role requires MD/DO, board certification, and active state licensure with 5 years clinical care experience. You will participate in CMDM rounds, help develop protocols, and drive special projects while ensuring compliance with NCQA/URAC/CMS regulations.

Qualifications

• MD or DO required with board certification.
• Active medical state licensure required; multiple state licensure may be needed.
• Minimum 5 years of direct clinical care experience.
• Preferred: MBA or MPH and knowledge of managed care.

Responsibilities

• Review escalated cases against medical policy criteria to determine medical necessity.
• Participate in CMDM multidisciplinary team, attend huddles and grand rounds.
• Contribute to protocol and guideline development and lead/participate in projects.
• Adhere to NCQA, URAC, CMS, DOH, and DOL regulations and maintain compliance.

Education

MD or DO

Board Certification

Active medical license

MBA or MPH (preferred)

Job description

Highmark Inc. in Charleston, WV seeks an experienced physician to join a utilization management team. You will review escalated cases, determine medical necessity, and engage in peer discussions as needed.

The role requires MD/DO, board certification, and active state licensure with 5 years clinical care experience. You will participate in CMDM rounds, help develop protocols, and drive special projects while ensuring compliance with NCQA/URAC/CMS regulations.