Medical Director - Utilization & Care Management Leader

Highmark Health; Columbus (OH); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health seeks a physician to perform utilization management within a multidisciplinary team, reviewing escalated cases against medical policy to determine medical necessity. The role emphasizes compliance with NCQA, URAC, CMS, DOH, and DOL standards and may involve telephonic peer-to-peer discussions.

The position requires an MD or DO, active medical licensure, board certification, and at least 5 years of clinical care experience; a Master’s in Business Administration or Public Health is

Qualifications

• MD or DO with active medical licensure
• Board certification by the American Board of Medical Specialties or the American Osteopathic Association
• 5 years in clinical direct patient care (hospital, outpatient, or private practice)
• Preferred: Master’s in Business Administration/Management or Public Health

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate as a CMDM multidisciplinary team member and advise on cases requiring physician expertise.
• Develop protocols and guidelines to ensure consistency in review processes.
• Actively manage projects or participate on project teams requiring physician SME involvement.
• Perform other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

Computer Skills

Clinical Software

Managed Care

Education

MD/DO

MBA/MPH (Preferred)

Job description

Highmark Health seeks a physician to perform utilization management within a multidisciplinary team, reviewing escalated cases against medical policy to determine medical necessity. The role emphasizes compliance with NCQA, URAC, CMS, DOH, and DOL standards and may involve telephonic peer-to-peer discussions.

The position requires an MD or DO, active medical licensure, board certification, and at least 5 years of clinical care experience; a Master’s in Business Administration or Public Health is