Medical Director, Utilization & Case Management

Highmark Health; Santa Fe (NM); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health is seeking a physician leader to oversee utilization management within a multidisciplinary team. You will review escalated cases against medical policy, participate in peer discussions, and ensure compliance with regulatory standards to protect member care quality.

Required MD/DO with active license and board certification; 5 years of direct clinical care. MBA/MPH preferred for strategic oversight and project leadership.

Qualifications

• MD/DO required.
• 5 years of clinical direct patient care.
• ABMS/AOA board certification required.
• Active medical license required.
• MBA/MPH preferred for broader management.

Responsibilities

• Review escalated cases using medical policy to assess medical necessity.
• Engage in telephonic peer-to-peer discussions as needed.
• Ensure compliance with NCQA, URAC, CMS, DOH, and DOL regulations.
• Participate on the CMDM multidisciplinary team and advise on high-risk cases.
• Lead protocol and guidelines development; manage physician-led projects.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Board Certification

Medical Licensure

MBA/MPH (Preferred)

Job description

Highmark Health is seeking a physician leader to oversee utilization management within a multidisciplinary team. You will review escalated cases against medical policy, participate in peer discussions, and ensure compliance with regulatory standards to protect member care quality.

Required MD/DO with active license and board certification; 5 years of direct clinical care. MBA/MPH preferred for strategic oversight and project leadership.