Medical Director, Utilization & Care Management

Highmark Health; Oklahoma City (OK); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to perform utilization management as part of a multidisciplinary team. You will review escalated cases against policy criteria, determine medical necessity, and participate in peer discussions when needed.

The role emphasizes compliance with NCQA/URAC/CMS/DOL guidelines, care management, and special projects with physician input. Requires MD/DO and board certification, with licensure to practice in applicable states.

Qualifications

• MD or DO required.
• Board Certification in specialty recognized by ABMS or AOA.
• Active medical state licensure required; additional state licensure may be needed.

Responsibilities

• Conduct electronic reviews of escalated cases against medical policy criteria to determine medical necessity.
• Participate as a CMDM multidisciplinary team member and advise on high-risk cases.
• Develop protocols/guidelines to ensure consistency in reviews.
• Lead or participate in physician-led projects related to medical management.
• 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/DO

MBA/MPH (Preferred)

Job description

Highmark Inc. is seeking a physician to perform utilization management as part of a multidisciplinary team. You will review escalated cases against policy criteria, determine medical necessity, and participate in peer discussions when needed.

The role emphasizes compliance with NCQA/URAC/CMS/DOL guidelines, care management, and special projects with physician input. Requires MD/DO and board certification, with licensure to practice in applicable states.