Medical Director - Utilization & Care Management

Highmark Health; Columbus (OH); On-site; USD 190,000 - 290,000; Full time

Job summary

Highmark Inc. seeks an experienced physician to perform utilization management within a multidisciplinary team. You will review escalated cases electronically, assess medical necessity using policy criteria, and participate in peer-to-peer discussions as needed. Compliance with NCQA, URAC, CMS, DOH, and DOL regulations is essential.

The role includes advising on high-risk cases, contributing to protocol development, and leading projects to improve member care within a health plan setting.

Qualifications

• MD or DO degree required.
• Active medical state licensure required.
• Board certification by ABMS or AOA recognized boards.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine necessity and appropriateness.
• Participate in CMDM multidisciplinary team meetings and advise on high-risk cases.
• Develop and follow protocols to ensure consistency in the review process.
• Lead or participate in physician-led projects to enhance care management.
• Adhere to NCQA, URAC, CMS, DOH, and DOL regulations at all times.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Job description

Highmark Inc. seeks an experienced physician to perform utilization management within a multidisciplinary team. You will review escalated cases electronically, assess medical necessity using policy criteria, and participate in peer-to-peer discussions as needed. Compliance with NCQA, URAC, CMS, DOH, and DOL regulations is essential.

The role includes advising on high-risk cases, contributing to protocol development, and leading projects to improve member care within a health plan setting.