Physician Leader, Utilization & Care Management

Highmark Health

Tallahassee (FL)

On-site

USD 228,000 - 385,000

Full time

14 days+

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Job summary

Highmark Health in Florida seeks a physician to perform utilization management in a team setting, ensuring care aligns with top clinical standards. The role reviews escalated cases electronically using Medical Policy criteria, with potential telephonic peer discussions, and ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations.

You will be part of the CMDM multidisciplinary team, attend huddles and grand rounds, and contribute to protocol development while leading or participating in

Qualifications

MD or DO required.
Board certification in specialty recognized by ABMS/AOA.
Active medical license; state requirements may vary.

Responsibilities

Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
Participate in CMDM multidisciplinary team; attend huddles/grand rounds and advise on cases needing physician input.
Participate in protocol and guidelines development for consistent review processes.
Actively manage projects or join project teams requiring physician subject matter expertise.
Other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication Skills

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO (Medical Doctor or Doctor of Osteopathic Medicine)

Board Certification (ABMS/AOAS)

Active medical license

Tools

None

Job description

You will be part of the CMDM multidisciplinary team, attend huddles and grand rounds, and contribute to protocol development while leading or participating in

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