Part-Time Weekend Medical Director (Remote)

Lensa; Raleigh (NC); Remote; USD 170,000 - 343,000; Full time

Job summary

An established industry player is seeking a skilled physician to join their utilization management team. This role involves reviewing escalated cases, ensuring compliance with clinical standards, and advising multidisciplinary teams on high-risk cases. The ideal candidate will have a strong background in clinical care and medical management, with a focus on improving patient outcomes. This position offers a competitive salary and the opportunity to make a significant impact in a dynamic healthcare environment. If you are passionate about healthcare and want to contribute to innovative solutions, this role is perfect for you.

Qualifications

• 5+ years in Clinical, Direct Patient care (hospital, outpatient, or private practice).
• Board Certification in recognized specialty and active medical license required.

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 subject matter expertise.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

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 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, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations 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 the 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 DO, Board Certification in recognized specialty, active medical license (state-specific requirements may vary)

• Preferred: None

Skills:

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

Additional Information:

Travel required: 0%-25%

Position type: Office-based, teaching/training, occasional travel, physical demands as specified.

Pay Range: $170,000 - $342,274 annually.

Compliance: Adherence to HIPAA, privacy policies, and company conduct standards is required.