Medical Director, Utilization & Care Management

Highmark Health; Dover (DE); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to lead utilization management within a multidisciplinary team. You will review escalated cases, determine medical necessity, and participate in peer discussions when needed.

In addition to clinical review, you will contribute to policy development and act as a physician SME on projects, ensuring compliance with NCQA, URAC, CMS, and related regulations.

Qualifications

• MD or DO with medical licensure; board certification active.
• Experience in clinical management and guidance within health plans.
• Strong written and verbal communication; team collaboration.

Responsibilities

• Review escalated cases electronically against medical policy to determine necessity.
• Participate in CMDM multidisciplinary team; advise on high-risk cases.
• Contribute to protocol/guideline development for review consistency.
• Lead or participate in physician-led projects and teams.
• Perform other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

MBA or MPH (preferred)

Job description

Highmark Inc. is seeking a physician to lead utilization management within a multidisciplinary team. You will review escalated cases, determine medical necessity, and participate in peer discussions when needed.

In addition to clinical review, you will contribute to policy development and act as a physician SME on projects, ensuring compliance with NCQA, URAC, CMS, and related regulations.