Medical Utilization & Care Management Director

Highmark Health; Concord (NH); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Health is seeking a physician to join a multidisciplinary utilization management team in Concord, NH. The role evaluates medical necessity, reviews escalated cases, and ensures compliance with NCQA/URAC/CMS/DOH/DOL standards.

Telephonic peer discussions may be required to support clinical decisions. Responsibilities include participating in CMDM rounds, contributing to protocol development, and guiding care management for high-risk members; 5+ years clinical experience and board

Qualifications

• MD/DO required.
• Board Certification in a specialty recognized by ABMS or AAOSB. Active medical state licensure required.
• Minimum 5 years in Clinical direct patient care.
• Preferred 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness with required compliance.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds; advise on physician-expert cases.
• Participate in protocol and guidelines development for consistent review processes.
• Actively manage projects or participate on project teams requiring physician SME.
• Other duties as assigned.

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

MBA/MPH preferred

Job description

Highmark Health is seeking a physician to join a multidisciplinary utilization management team in Concord, NH. The role evaluates medical necessity, reviews escalated cases, and ensures compliance with NCQA/URAC/CMS/DOH/DOL standards.

Telephonic peer discussions may be required to support clinical decisions. Responsibilities include participating in CMDM rounds, contributing to protocol development, and guiding care management for high-risk members; 5+ years clinical experience and board