Medical Director: Utilization & Care Management

Highmark Health; Indianapolis (IN); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to join a multidisciplinary team focused on utilization management and care coordination. The role involves electronic reviews, policy-based determinations, and collaboration with CMDM for high-risk cases.

Requirements include MD/DO, board certification, and active licensure; a master’s in business/public health is preferred. The position emphasizes compliance with NCQA, URAC, CMS, and related standards and offers opportunities to influence care pathways.

Qualifications

• MD or DO required.
• Board Certification in a relevant specialty required.
• Active medical state licensure required; other state licenses may be needed based on business need.
• Master's degree in business/public health preferred.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate as a CMDM team member and advise on high-risk cases.
• Develop protocols/guidelines to ensure consistency in the review process.
• Lead or participate in physician-led projects within the health plan.
• Perform 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 or DO

Board Certification (ABMS/AOA)

Active medical state licensure

Master's in Business Administration/Management or Public Health (preferred)

Job description

Highmark Inc. is seeking a physician to join a multidisciplinary team focused on utilization management and care coordination. The role involves electronic reviews, policy-based determinations, and collaboration with CMDM for high-risk cases.

Requirements include MD/DO, board certification, and active licensure; a master’s in business/public health is preferred. The position emphasizes compliance with NCQA, URAC, CMS, and related standards and offers opportunities to influence care pathways.