Part-Time Weekend Medical Director (Remote)

Lensa; Springfield (IL); Remote; USD 170,000 - 343,000; Full time

Job summary

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

Qualifications

• 5 years in clinical or direct patient care required.
• 1 year in medical management preferred.

Responsibilities

• Conduct electronic reviews of cases to determine medical necessity.
• Participate in multidisciplinary team meetings.
• Contribute to protocol and guideline development.

Skills

Critical thinking

Case management

Customer service

Communication skills

Collaboration

Listening

Telephone skills

Computer skills

Clinical software

Managed care knowledge

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

ESSENTIAL RESPONSIBILITIES

• Conduct electronic reviews of cases, including telephonic peer discussions, to determine medical necessity and appropriateness, and compose clear rationales for notifications, ensuring compliance with standards.
• Participate in multidisciplinary team meetings, advise on cases requiring physician expertise.
• Contribute to protocol and guideline development for review process consistency.
• Manage or participate in projects requiring physician expertise.
• 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 or direct patient care.
• Preferred: 1 year in medical management within a health insurance plan and managed care knowledge.

LICENSES AND CERTIFICATIONS

• MD or DO with active medical license.
• 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, computer skills, clinical software, managed care knowledge.

Additional Details

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

Compensation

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

Equal Opportunity

Highmark Health is an EEO/AA employer and prohibits discrimination. For accessibility or accommodation requests, contact HR Services.