Part-Time Weekend Medical Director (Remote)

Lensa; Salt Lake City (UT); Remote; USD 170,000 - 343,000; Part time

Job summary

A leading health care provider is seeking a physician to join their team for utilization management. The role involves reviewing cases for medical necessity, participating in multidisciplinary teams, and contributing to protocol development. Candidates should possess a medical degree and relevant experience in clinical settings. This part-time position offers a salary range based on qualifications and experience, with minimal travel required.

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 or participate in projects requiring physician expertise.

Skills

Critical thinking

Case management

Customer service

Communication skills

Collaboration

Listening

Telephone skills

General computer skills

Clinical software

Managed care knowledge

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, advising on cases, particularly high-risk ones. The incumbent may also be assigned special projects to support and improve member care.

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 notifications, adhering to compliance standards (NCQA, URAC, CMS, DOH, DOL, etc.). Ensure medical management processes align with community standards of care.
2. Participate as a member of the CMDM multidisciplinary team, attend huddles and grand rounds, and advise on cases requiring physician expertise.
3. Contribute to protocol and guideline development to ensure review process consistency.
4. Manage or participate in projects requiring physician expertise.
5. Perform 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 within a health insurance plan; strong managed care industry knowledge

Licenses and Certification :

• Active medical state licensure; Board certification recognized by the American Board of Medical Specialties or the American Osteopathic Association

Skills :

• Critical thinking, case management, customer service, communication skills, collaboration, listening, telephone skills, general computer skills, clinical software, managed care knowledge

Additional Information :

Travel required: 0% - 25%

Position type: Office-based, occasional travel, physical demands minimal, lifting up to 10 pounds frequently, 10-25 pounds rarely.

Compliance and confidentiality standards apply, including HIPAA and company privacy policies.

Salary Range :

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

Note: Salary varies based on qualifications, experience, and location.

Equal Opportunity Statement :

Highmark Health prohibits discrimination and promotes affirmative action. See EEOC poster link for details.

Additional Notes :

Accessibility and accommodation requests should be directed to HR.

Job Details :

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