Part-Time Weekend Medical Director (Remote)

Lensa; Madison (WI); Remote; USD 170,000 - 343,000; Part time

Job summary

A leading health organization is seeking a qualified Medical Doctor or Doctor of Osteopathic Medicine for a part-time role in utilization management. The position involves reviewing clinical cases and ensuring compliance with medical standards. Ideal candidates will have significant experience in clinical care and medical management, along with strong communication skills. This role offers the opportunity to work with a multidisciplinary team to enhance patient care.

Qualifications

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

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Participate as a member of the CMDM multidisciplinary team.
• Actively manage projects requiring physician expertise.

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 of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to 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, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.). Ensure that 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 multidisciplinary team on cases that require physician expertise.
3. Participate in protocol and guidelines development to ensure consistency in the review process.
4. Actively manage projects and/or participate on project teams that require 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)
• Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
• Active medical state licensure required. Additional specific 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

Physical and Working Conditions :

Position Type: Office-Based

Teaches / trains others regularly: Occasionally

Travel: 0% - 25%

Physical work site required: No

Lifting: Up to 10 pounds constantly; 10 to 25 pounds rarely; 25 to 50 pounds rarely.

Disclaimer: The job description indicates the general duties and responsibilities and may not include all duties, responsibilities, and qualifications.

Compliance: This job adheres to ethical and legal standards, including HIPAA and data security guidelines. Employees must comply with the company's Code of Business Conduct and applicable laws.

Pay Range: $170,000 - $342,274. Base pay depends on qualifications, experience, and market factors.

Highmark Health and affiliates promote equal opportunity employment and prohibit discrimination based on protected categories. For more info, visit the EEOC poster here.

Additional Details :

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