Medical Director, Utilization & Care Management

Highmark Health; Salem (OR); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. in Salem, Oregon, is seeking a physician reviewer to lead utilization management activities within a clinical team. You will assess medical necessity, review escalated cases, and discuss complex decisions with peers to ensure high-quality member care.

This role requires MD or DO, board certification, and current state licensure, with 5 years of direct patient care. Preference for MBA or MPH and experience in medical management within a health plan.

Qualifications

• MD or DO is required.
• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice).
• Active medical state licensure required; board certification in specialty recognized by ABMS/AOA.
• Preferred: 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry.

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 and advise on cases requiring physician expertise.
• Participate in protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician SME.
• 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 or DO

MBA or MPH (preferred)

Job description

Highmark Inc. in Salem, Oregon, is seeking a physician reviewer to lead utilization management activities within a clinical team. You will assess medical necessity, review escalated cases, and discuss complex decisions with peers to ensure high-quality member care.

This role requires MD or DO, board certification, and current state licensure, with 5 years of direct patient care. Preference for MBA or MPH and experience in medical management within a health plan.