Medical Director, Utilization & Case Management

Highmark Health; Lansing (MI); Presencial; USD 200.000 - 320.000; Jornada completa

Descripción de la vacante

Highmark Inc. is seeking a physician to join a team focused on utilization management. The role reviews escalated cases electronically, applying Medical Policy criteria to determine medical necessity and appropriateness, potentially involving telephonic peer-to-peer discussions.

The physician will ensure compliance with NCQA, URAC, CMS, DOH, DOL and participate in disease management as part of a CMDM team. The position requires MD or DO, active state licensure, and 5 years of direct patient care

Formación

• MD or DO required
• Active medical licensure required; board certification
• 5 years clinical direct patient care
• MBA/MPH preferred

Responsabilidades

• Review escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate in the CMDM multidisciplinary team; advise on high‑risk cases.
• Develop protocols and guidelines to ensure consistency in the review process.
• Manage projects as a physician SME and support special initiatives.

Descripción del empleo

Highmark Inc. is seeking a physician to join a team focused on utilization management. The role reviews escalated cases electronically, applying Medical Policy criteria to determine medical necessity and appropriateness, potentially involving telephonic peer-to-peer discussions.

The physician will ensure compliance with NCQA, URAC, CMS, DOH, DOL and participate in disease management as part of a CMDM team. The position requires MD or DO, active state licensure, and 5 years of direct patient care