Medical Director – Utilization & Care Management

highmarkhealth; Pennsylvania; Hybrid; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. in Pennsylvania seeks a physician to join a team focused on utilization management, aligning practice with top clinical standards. The role reviews escalated cases electronically and using Medical Policy criteria to assess medical necessity and appropriateness of requested treatments.

Telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and participates on the CMDM multidisciplinary team for case and

Qualifications

• MD or DO required with medical license.
• Board certification in a relevant specialty.
• Active medical state licensure required; additional state licensure may be needed.
• Preferred: MBA or MPH.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds.
• Develop protocols and guidelines to ensure consistency in the review process.
• Lead or participate in physician-led projects to support and improve member care.
• 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/MPH preferred

Job description

Highmark Inc. in Pennsylvania seeks a physician to join a team focused on utilization management, aligning practice with top clinical standards. The role reviews escalated cases electronically and using Medical Policy criteria to assess medical necessity and appropriateness of requested treatments.

Telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations and participates on the CMDM multidisciplinary team for case and