Medical Director, Utilization & Care Management

Highmark Health; Raleigh (NC); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health is seeking a physician reviewer to join a physician team and ensure utilization management aligns with current clinical standards. You will review escalated cases using Medical Policy criteria to evaluate medical necessity, and may engage in telephonic peer-to-peer discussions as needed.

The role includes participating in CMDM multidisciplinary rounds, advising on high-risk cases, and contributing to protocol development to standardize review processes.

Qualifications

• MD or DO required.
• Active medical state licensure required.
• Board Certification in an ABS or Osteopathic specialty.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria and determine medical necessity.
• Participate as a CMDM multidisciplinary team member and advise on high‑risk cases.
• Develop/protocols and guidelines to ensure consistency in the review process.
• Actively manage projects or participate on teams requiring physician SME.
• 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)

Doctor of Osteopathic Medicine (DO)

Job description

Highmark Health is seeking a physician reviewer to join a physician team and ensure utilization management aligns with current clinical standards. You will review escalated cases using Medical Policy criteria to evaluate medical necessity, and may engage in telephonic peer-to-peer discussions as needed.

The role includes participating in CMDM multidisciplinary rounds, advising on high-risk cases, and contributing to protocol development to standardize review processes.