Part-Time Weekend Medical Director (Remote)

Lensa; Sacramento (CA); Remote; USD 170,000 - 343,000; Full time

Job summary

Join a leading health organization as a physician team member, ensuring the highest clinical standards in utilization management. You'll review cases, advise multidisciplinary teams, and participate in project management to enhance member care. This role requires an MD or DO and offers a competitive salary range based on experience and qualifications.

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 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 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 :

• 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.
• Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
• Participate in protocol and guidelines development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician subject matter expert.
• 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.

Preferred

• None

SKILLS :

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

Additional Information :

Travel required: 0% - 25%

Position type: Office-Based

Physical demands include occasional lifting up to 25 pounds. Work involves teaching/training, travel between sites, and working in an office environment.

Disclaimer: This job description indicates the general nature and essential duties and responsibilities but may not contain all duties or qualifications.

Compliance: Employees must adhere to ethical, legal, and behavioral standards, including HIPAA and data security policies.

Pay Range :

Minimum: $170,000.00

Maximum: $342,274.00

Salary is based on qualifications, experience, and market factors.

Equal Opportunity Statement :

Highmark Health is an EEO employer, prohibiting discrimination and promoting affirmative action.