Medical Director, Utilization & Case Management

Highmark Health; Austin (TX); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health seeks a physician reviewer to perform utilization management within a multidisciplinary CMDM team. You will assess escalated cases against policy criteria and participate in peer discussions when needed to determine medical necessity and appropriateness.

You will contribute to protocol development, engage in special projects, and ensure compliance with NCQA, URAC, CMS, DOH, and DOL regulations while maintaining high standards of patient care.

Qualifications

• MD or DO required.
• Active medical state licensure required; board certification.
• Experience in clinical management or health plan settings is preferred.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity.
• Participate as a CMDM team member; advise on high-risk cases.
• Develop protocols/guidelines to standardize the review process.
• Lead or participate in physician-facilitated projects and programs.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Master's Degree in Business Administration/Management or Public Health

Job description

Highmark Health seeks a physician reviewer to perform utilization management within a multidisciplinary CMDM team. You will assess escalated cases against policy criteria and participate in peer discussions when needed to determine medical necessity and appropriateness.

You will contribute to protocol development, engage in special projects, and ensure compliance with NCQA, URAC, CMS, DOH, and DOL regulations while maintaining high standards of patient care.