Medical Director, Utilization & Care Management

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

Job summary

Highmark Inc. seeks a physician to join a multidisciplinary team to oversee utilization management, review escalated cases, and apply Medical Policy criteria to determine medical necessity.

Telephonic peer discussions may be required to support clinical decisions, ensuring compliance with NCQA, URAC, CMS, DOH, and DOL standards. The role involves advising on high-risk cases, contributing to disease management programs, and participating in special projects to improve member care, with travel

Qualifications

• MD or DO required and board-certified in a relevant specialty.
• Active medical state licensure required; additional state licensure may be needed.
• Preferred: MBA or MPH for broader program management.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity.
• Participate in CMDM multidisciplinary team; attend huddles and grand rounds, advising on high-risk cases.
• Develop protocols to ensure consistency in the review process and participate in special projects.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Master's Degree in Business Administration/Management or Public Health

Job description

Highmark Inc. seeks a physician to join a multidisciplinary team to oversee utilization management, review escalated cases, and apply Medical Policy criteria to determine medical necessity.

Telephonic peer discussions may be required to support clinical decisions, ensuring compliance with NCQA, URAC, CMS, DOH, and DOL standards. The role involves advising on high-risk cases, contributing to disease management programs, and participating in special projects to improve member care, with travel