Part-Time Weekend Medical Director (Remote)

Lensa; Santa Fe (NM); Remote; USD 170,000 - 343,000; Full time

Job summary

A leading healthcare organization is seeking a physician to join their utilization management team. The role involves reviewing medical necessity cases, participating in multidisciplinary teams, and ensuring compliance with clinical standards. Ideal candidates will have a medical degree and extensive clinical experience.

Qualifications

• 5 years in clinical/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 multidisciplinary team.
• Contribute to protocol and guideline development.

Skills

Critical Thinking

Case Management

Customer Service

Communication

Collaboration

Listening

Telephone Skills

Computer Skills

Clinical Software

Managed Care

Education

MD or DO

Master's in Business Administration/Management

Master's in Public Health

Job description

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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This role involves working as part of a physician team to ensure utilization management responsibilities meet current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria to evaluate the medical necessity and appropriateness of treatments or services. Telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Additionally, they participate in case and disease management as a physician member of a multidisciplinary team, advising on high-risk cases and supporting projects to improve member care.

ESSENTIAL RESPONSIBILITIES

1. Conduct electronic review of escalated cases against medical policy criteria, including peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations, reviews of appeals and grievances, and compose clear rationales for notifications, ensuring compliance with standards.
2. Participate as a member of the multidisciplinary team, attend huddles and rounds, and advise on cases requiring physician expertise.
3. Contribute to protocol and guideline development for review process consistency.
4. Manage or participate in projects requiring physician expertise.
5. Perform other duties as assigned.

Education

• Required: MD or DO

• Preferred: Master's in Business Administration/Management or Public Health

Experience

• Required: 5 years in clinical/patient care (hospital, outpatient, private practice)

• Preferred: 1 year in medical management within a health insurance plan and managed care industry knowledge

Licenses and Certification

• MD or DO
• Board certification recognized by ABMS or AOA
• Active medical license; additional state licenses may be required

Skills

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

Additional Details

Travel required: 0-25%. Position is office-based with occasional travel. Physical demands include lifting up to 25 pounds rarely. The role adheres to ethical, legal, and confidentiality standards, including HIPAA, and requires compliance with company policies.

Compensation

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

Equal Opportunity Statement

Highmark Health is an EEO employer, prohibiting discrimination based on protected categories. For accommodations, contact HR.

Additional Information

Req ID: J254551

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