Medical Director, Utilization & Care Management

Highmark Health; United States; Remote; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. seeks a physician to join a utilization management team. You will review escalated cases against medical policy, determine medical necessity, and participate in care management as part of a multidisciplinary CMDM.

Telephonic peer-to-peer discussions may be required, with compliance to NCQA, URAC, CMS, DOH and DOL standards. Requirements include MD or DO, board certification, active state license, and 5 years of direct clinical experience. Travel 0-25%.

Qualifications

• MD or DO required for the role.
• Active medical state licensure required; board certification in a relevant specialty.
• Preferred MBA or MPH related to health administration or public health.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Determine medical necessity and appropriateness of treatments.
• Participate in CMDM multidisciplinary team and medical management.
• Attend huddles/grand rounds and advise on high-risk cases.
• Develop protocols/guidelines to ensure review consistency.

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 required

MBA/MPH preferred

Job description

Highmark Inc. seeks a physician to join a utilization management team. You will review escalated cases against medical policy, determine medical necessity, and participate in care management as part of a multidisciplinary CMDM.

Telephonic peer-to-peer discussions may be required, with compliance to NCQA, URAC, CMS, DOH and DOL standards. Requirements include MD or DO, board certification, active state license, and 5 years of direct clinical experience. Travel 0-25%.