Medical Director, Utilization & Case Management

Highmark Health; Frankfort (KY); Sur place; USD 228 000 - 385 000; Plein temps

Résumé du poste

Highmark Inc. seeks a physician leader to oversee utilization management within a multidisciplinary CMDM team.

You will review escalated cases using medical policy criteria to assess medical necessity and appropriateness, supporting high-risk cases and contributing to care improvements. Role entails participating in protocol development, attending rounds, and guiding complex decision-making while ensuring compliance with NCQA, URAC, CMS, DOH, and DOL regulations.

Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) required.
• Board Certification in relevant specialty (ABMS/AOA) required.
• Active medical state licensure required; additional state licenses may be needed.

Responsabilités

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Attend huddles and grand rounds; advise multidisciplinary team on cases requiring physician expertise.
• Develop protocols and guidelines to ensure consistency in review processes.
• Lead or participate in projects requiring physician subject matter expertise.
• Other duties as assigned.

Connaissances

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Formation

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

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

Description du poste

Highmark Inc. seeks a physician leader to oversee utilization management within a multidisciplinary CMDM team.

You will review escalated cases using medical policy criteria to assess medical necessity and appropriateness, supporting high-risk cases and contributing to care improvements. Role entails participating in protocol development, attending rounds, and guiding complex decision-making while ensuring compliance with NCQA, URAC, CMS, DOH, and DOL regulations.