Medical Director, Utilization & Case Management

Highmark Health; Boston (MA); Presencial; USD 228 000 - 385 000; Tempo integral

Resumo da oferta

Highmark Inc. is seeking a physician to join a collaborative team responsible for utilization management, ensuring clinical criteria guide medical necessity decisions across cases.

The role includes reviewing escalated cases, participating in the CMDM multidisciplinary team, contributing to protocol development, and leading special projects to improve member care while complying with NCQA, URAC, CMS, DOH, and DOL regulations.

Qualificações

• MD or DO required.
• Active medical state licensure required.
• Board Certification in specialty recognized by ABMS or AOA required.

Responsabilidades

• 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 complex cases.
• Develop and align review protocols and guidelines for consistency in the process.
• Lead or participate in projects that require physician SME input.

Conhecimentos

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Formação académica

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

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

Descrição da oferta de emprego

Highmark Inc. is seeking a physician to join a collaborative team responsible for utilization management, ensuring clinical criteria guide medical necessity decisions across cases.

The role includes reviewing escalated cases, participating in the CMDM multidisciplinary team, contributing to protocol development, and leading special projects to improve member care while complying with NCQA, URAC, CMS, DOH, and DOL regulations.