Remote Medical Director: Utilization & Care Management

Highmark Health; Louisiana; Ibrido; USD 228.000 - 385.000; Tempo pieno

Descrizione del lavoro

Highmark Inc. is seeking a Medical Director to lead utilization management and ensure care aligns with current clinical standards.

You will review escalated cases against policy criteria, engage in peer-to-peer discussions when needed, and ensure compliance with NCQA, URAC, CMS, and state regulations. You will participate in the CMDM multidisciplinary team, advise on high-risk cases, and help develop protocols while leading or contributing to strategic projects within a health plan.

Competenze

• MD or DO medical degree required.
• MBA or MPH preferred for management/public health.
• Active medical license required. Board certification in specialty recognized by ABMS or AOA.

Mansioni

• Conduct electronic review of escalated cases against medical policy criteria, including telephonic peer-to-peer discussions.
• Determine medical necessity and appropriateness of requested treatment.
• Prepare clear rationales for member and provider notifications in compliance with NCQA, URAC, CMS, DOH, and DOL rules.
• Participate in the CMDM multidisciplinary team; attend huddles and grand rounds.
• Contribute to protocol/guideline development; manage projects requiring physician SME input.

Conoscenze

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Formazione

MD/DO

MBA/MPH

Descrizione del lavoro

Highmark Inc. is seeking a Medical Director to lead utilization management and ensure care aligns with current clinical standards.

You will review escalated cases against policy criteria, engage in peer-to-peer discussions when needed, and ensure compliance with NCQA, URAC, CMS, and state regulations. You will participate in the CMDM multidisciplinary team, advise on high-risk cases, and help develop protocols while leading or contributing to strategic projects within a health plan.