Part-Time Weekend Medical Director (Remote)

Lensa; Washington (District of Columbia); Remote; USD 170,000 - 343,000; Full time

Job summary

A leading healthcare organization is seeking a qualified MD or DO to join their physician team for utilization management. The role involves reviewing cases, ensuring compliance with regulations, and contributing to patient care improvement projects. Ideal candidates will have extensive clinical experience and strong skills in case management and communication.

Qualifications

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

Responsibilities

• Conduct electronic reviews of cases against medical policy criteria.
• Participate in multidisciplinary team meetings and provide case advice.
• Manage or participate in projects requiring physician expertise.

Skills

Critical thinking

Case management

Customer service

Communication

Collaboration

Listening

Telephone skills

General computer skills

Clinical software

Managed care

Education

MD or DO

Master's in Business Administration/Management or 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 perform utilization management in accordance with current clinical standards. The incumbent reviews escalated cases electronically and via Medical Policy criteria to assess the medical necessity of treatments, possibly engaging in telephonic peer-to-peer discussions. Ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Participates in case and disease management, advising the multidisciplinary team, especially on high-risk cases, and may support special projects to improve member care.

ESSENTIAL RESPONSIBILITIES

• Conduct electronic reviews of cases against medical policy criteria, including telephonic discussions, to determine necessity and appropriateness. Complete initial case determinations, reviews of appeals, grievances, and draft notifications adhering to compliance standards. Ensure medical management aligns with community standards of care.
• Participate in multidisciplinary team meetings, provide case advice, and attend huddles and grand rounds.
• Contribute to protocol and guideline development for review processes.
• 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 (hospital, outpatient, private practice)

Preferred:

• 1 year in medical management within a health insurance plan; strong managed care industry knowledge

LICENSES AND CERTIFICATIONS

• MD or DO
• Active medical license; Board certification recognized by ABMS or AOA

Skills

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

Additional Details

Position is office-based with some travel (0-25%), occasional training, and rare physical lifting requirements. Complies with all applicable legal, ethical, and privacy standards, including HIPAA. Salary range: $170,000 - $342,274. Highmark Health is an equal opportunity employer.