Part-Time Weekend Medical Director (Remote)

Lensa; Columbus (OH); Remote; USD 170,000 - 343,000; Part time

Job summary

A leading health organization is looking for a physician to join their utilization management team. The role involves reviewing medical necessity, advising on high-risk cases, and ensuring compliance with regulations. Ideal candidates will have a strong clinical background and experience in medical management. This part-time position offers competitive pay and opportunities for professional growth.

Qualifications

• 5 years in Clinical, Direct Patient care required.
• 1 year in Medical Management preferred.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Participate as a member of the CMDM multidisciplinary team.
• Manage projects requiring a physician subject matter expert.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

Master's Degree in Business Administration/Management

Master's Degree in Public Health

Job description

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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment or service. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members.

ESSENTIAL RESPONSIBILITIES :

1. Conduct electronic review of escalated cases against medical policy criteria, including telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations, reviews of appeals and grievances, and other reviews as assigned. Compose clear rationales for member and provider determination notifications, adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). Ensure all aspects of the medical management process are consistent with community standards of care.
2. Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the team on cases requiring physician expertise.
3. Participate in protocol and guideline development to ensure review process consistency.
4. Manage projects and/or participate in project teams requiring a physician subject matter expert.
5. Other duties as assigned.

EDUCATION :

Required:

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

Preferred:

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

EXPERIENCE :

Required:

• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)

Preferred:

• 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry

LICENSES AND CERTIFICATION :

Required:

• Medical Doctor or Doctor of Osteopathic Medicine (DO)
• Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Osteopathic Association
• Active medical state licensure; additional state licensure(s) may be required based on business need.

Skills :

• Critical Thinking
• Case Management
• Customer Service
• Oral & Written Communication Skills
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

Travel :

0% - 25%

Physical, Mental Demands, and Working Conditions :

Office-Based; occasional travel; physical demands include lifting up to 10-25 pounds rarely; physical work site not required.

Disclaimer: The job description indicates the general nature and essential duties of the role. It may not include all duties, responsibilities, and qualifications.

Compliance: Employees must adhere to ethical and legal standards, protect confidential information per HIPAA, and comply with company policies and applicable laws.

Pay Range :

Minimum: $170,000.00; Maximum: $342,274.00

Base pay depends on qualifications, experience, contributions, internal equity, market, and location considerations.

Highmark Health and affiliates prohibit discrimination and promote affirmative action.

EEO statement and contact information for accessibility and accommodation requests included.

Additional Details :

• Seniority level: Mid-Senior level
• Employment type: Part-time
• Job function: Health Care Provider
• Industries: IT Services and IT Consulting