Medical Director, Utilization & Care Management

Highmark Health; Sacramento (CA); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health seeks a physician to perform utilization management within a multidisciplinary team in California. You will review escalated cases for medical necessity using policy criteria and participate in disease management discussions with peers.

The role requires MD/DO licensure, board certification, and at least 5 years of direct patient care experience. Strong collaboration and communication skills are essential to support compliant, high-quality member care.

Qualifications

• MD or DO with medical licensure
• Minimum 5 years in clinical direct patient care
• Board certification in a relevant specialty
• Active medical state licensure required; multi-state may be needed

Responsibilities

• Review escalated cases electronically against medical policy to determine medical necessity and appropriateness.
• Participate in CMDM multidisciplinary meetings and advise on high-risk cases.
• Contribute to protocol and guideline development for consistent review processes.
• Lead or participate in physician-led projects to improve care management.
• Comply with NCQA, URAC, CMS, DOH, and DOL standards in all activities.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD or DO

MBA or MPH (preferred)

Tools

None

Job description

Highmark Health seeks a physician to perform utilization management within a multidisciplinary team in California. You will review escalated cases for medical necessity using policy criteria and participate in disease management discussions with peers.

The role requires MD/DO licensure, board certification, and at least 5 years of direct patient care experience. Strong collaboration and communication skills are essential to support compliant, high-quality member care.