Medical Director — Utilization & Care Management

Highmark Health; Columbia (SC); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. in Columbia, SC is seeking a physician to join our team to perform utilization management in accordance with current clinical standards.

You will review escalated cases electronically using Medical Policy criteria, and may participate in telephonic peer-to-peer discussions to determine medical necessity and appropriateness. As a member of the CMDM multidisciplinary team, you will advise on high-risk cases, support protocol development, and contribute to special projects aimed at

Qualifications

• Medical Doctor or Doctor of Osteopathic Medicine required.
• Board Certification in a specialty recognized by ABMS or AOA required.
• Active medical state licensure; additional state licensure may be required based on business need.
• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice).
• Preferred: MBA or MPH in Business Administration/Public Health.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria, including possible telephonic peer-to-peer discussions.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds.
• Contribute to protocol and guidelines development to ensure consistency.
• Lead or participate in projects requiring physician SME input.
• 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

MD/DO

MBA/MPH (preferred)

Job description

Highmark Inc. in Columbia, SC is seeking a physician to join our team to perform utilization management in accordance with current clinical standards.

You will review escalated cases electronically using Medical Policy criteria, and may participate in telephonic peer-to-peer discussions to determine medical necessity and appropriateness. As a member of the CMDM multidisciplinary team, you will advise on high-risk cases, support protocol development, and contribute to special projects aimed at