Medical Director, Utilization & Care Management

Highmark Health; Montgomery (AL); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health seeks a physician leader to perform utilization management within a multidisciplinary team. You will review escalated cases electronically, evaluate medical necessity using policy criteria, and participate in peer discussions as needed.

Role emphasizes adherence to NCQA, URAC, CMS, and DOH/DOL regulations, plus involvement in disease management with the CMDM team. Strong communication and collaboration are essential.

Qualifications

• MD or DO required; active medical state licensure is required.
• Board certification in a specialty recognized by ABMS or AOA.
• 5 years in clinical direct patient care (hospital, outpatient, or private practice).
• Preferred: MBA or MPH.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity.
• Complete initial determinations, reviews of appeals/grievances, and write concise rationales.
• Participate as a CMDM team member; attend huddles and grand rounds; advise on cases needing physician input.
• Assist in protocol and guidelines development to ensure consistency.
• Actively manage projects or join project teams requiring physician SME involvement.
• 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

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

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

Job description

Highmark Health seeks a physician leader to perform utilization management within a multidisciplinary team. You will review escalated cases electronically, evaluate medical necessity using policy criteria, and participate in peer discussions as needed.

Role emphasizes adherence to NCQA, URAC, CMS, and DOH/DOL regulations, plus involvement in disease management with the CMDM team. Strong communication and collaboration are essential.