Medical Director, Utilization & Care Management

Highmark Health; Topeka (KS); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking an experienced physician to join our utilization management team in a leadership capacity. You will review escalated cases, apply medical policy criteria, and determine medical necessity for treatments while maintaining regulatory compliance.

Telephonic peer discussions may be required, with collaboration across CMDM and other specialties. The role requires MD/DO, active state licensure, and at least 5 years of direct patient care; board certification is expected.

Qualifications

• MD or DO degree required; board certification in a related specialty.
• Active medical state license; additional state licensure may be required.
• 5 years’ clinical experience in hospital, outpatient, or private practice.
• Experience with medical management and managed care knowledge preferred.
• Board certification by ABMS or AOA preferred.

Responsibilities

• Review escalated cases electronically against medical policy criteria.
• Determine medical necessity and appropriateness of treatment.
• Participate on CMDM multidisciplinary team; advise on high-risk cases.
• Develop protocols and guidelines to ensure consistent reviews.
• Lead or participate in physician-led projects to improve care.

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 or MPH (preferred)

Job description

Highmark Inc. is seeking an experienced physician to join our utilization management team in a leadership capacity. You will review escalated cases, apply medical policy criteria, and determine medical necessity for treatments while maintaining regulatory compliance.

Telephonic peer discussions may be required, with collaboration across CMDM and other specialties. The role requires MD/DO, active state licensure, and at least 5 years of direct patient care; board certification is expected.