Part-Time Weekend Medical Director (Remote)

Lensa; Columbus (OH); Remote; USD 200,000 - 250,000; Full time

Job summary

A leading healthcare organization is seeking a physician to join their utilization management team. The role involves reviewing cases, ensuring compliance with regulations, and participating in multidisciplinary meetings to improve member care. Ideal candidates will have an MD or DO and significant clinical experience.

Qualifications

• 5 years in clinical or direct patient care required.

Responsibilities

• Conduct electronic reviews of escalated cases against medical policy criteria.
• Participate in multidisciplinary team meetings providing expert case advice.
• Contribute to protocol and guideline development.

Skills

Critical thinking

Case management

Communication

Collaboration

Listening

Telephone skills

General computer skills

Clinical software

Managed care knowledge

Education

MD or DO

Job description

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Company :

Highmark Inc.

Job Description :

JOB SUMMARY
This role involves working as part of a physician team to ensure utilization management responsibilities are performed according to current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria to evaluate the medical necessity and appropriateness of treatments or services. Telephonic peer-to-peer discussions may be required. The role requires compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Additionally, the incumbent participates as a physician member of the multidisciplinary team for case and disease management, advising on high-risk cases and supporting projects to improve member care.

ESSENTIAL RESPONSIBILITIES :

1. Conduct electronic reviews of escalated cases against medical policy criteria, including peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial case determinations, reviews of appeals and grievances, and draft clear rationales for notifications, adhering to compliance standards.
2. Participate in multidisciplinary team meetings, such as huddles and grand rounds, providing expert case advice.
3. Contribute to protocol and guideline development to ensure review process consistency.
4. Manage or participate in projects requiring physician expertise.
5. Perform other duties as assigned.

EDUCATION :

• Required: MD or DO

Experience :

• Required: 5 years in clinical or direct patient care (hospital, outpatient, or private practice).

Licenses and Certification :

• Required: MD or DO, Board certification, active state licensure.

Skills :

• Critical thinking, case management, communication, collaboration, listening, telephone skills, general computer skills, clinical software, managed care knowledge.

Additional Details :

This position is office-based with travel requirements of 0-25%. Physical demands include lifting up to 25 pounds occasionally. The role emphasizes adherence to ethical, legal, and confidentiality standards including HIPAA and company policies.