Part-Time Weekend Medical Director (Remote)

Lensa; Saint Paul (MN); Remote; USD 170,000 - 343,000; Part time

Job summary

An established industry player is seeking a dedicated physician to join their utilization management team. In this pivotal role, you will ensure compliance with the highest clinical standards while evaluating treatment requests and participating in multidisciplinary case management. Your expertise will guide high-risk cases and contribute to protocol development, enhancing patient care. This part-time position offers the opportunity to make a significant impact in a collaborative environment focused on improving health outcomes. If you are passionate about patient care and thrive in a dynamic setting, this role is for you.

Qualifications

• 5 years in Clinical, Direct Patient care required.
• Participate in protocol and guidelines development.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria.
• Advise multidisciplinary team on high-risk cases.

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) or Doctor of Osteopathic Medicine (DO)

Master's Degree in Business Administration/Management or 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

• 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)

Substitutions

• None

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 a 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

Travel Required

0% - 25%

Physical, Mental Demands and Working Conditions

Position Type: Office-Based

Teaches / trains others regularly: Occasionally

Travel regularly from the office to various work sites or from site-to-site: Rarely

Works primarily out-of-the office selling products/services (sales employees): Never

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 has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. All employees must comply with HIPAA, data security guidelines, and the company’s Code of Business Conduct, including adherence to applicable laws and regulations.

Pay Range: Minimum $170,000.00 - Maximum $342,274.00

Base pay is determined by various factors including qualifications, experience, contributions, internal equity, market, and business considerations. The salary range does not reflect geographic differentials.

Highmark Health and its affiliates prohibit discrimination and promote affirmative action regardless of protected categories. See EEOC poster.

For accessibility or accommodation requests, contact HR Services at [e-mail].

Req ID: J254551

Seniority level

• Mid-Senior level

Employment type

• Part-time

Job function

• Health Care Provider

Industries

• IT Services and IT Consulting