Senior Medical Director, Care Management & Utilization

Highmark Health Company; City of Albany (NY); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. seeks an experienced physician to lead utilization management activities within a multidisciplinary team in New York. You will review escalated cases, determine medical necessity, and participate in disease management discussions with peers and specialists.

Responsibilities include policy development, adherence to NCQA/URAC/CMS regulations, and driving care improvements for members. Prior medical management experience and board certification are highly valued.

Qualifications

• MD or DO required for eligibility.
• Board certification in a relevant specialty required or equivalent.
• Active medical licensure required; state-specific if needed.
• Preferred MBA/MPH for enhanced management insights.

Responsibilities

• Conduct electronic reviews of escalated cases against medical policy to determine medical necessity.
• Participate on the CMDM multidisciplinary team; advise on high-risk cases.
• Develop protocol/guidelines to ensure consistency in review processes.
• Lead or participate in projects requiring physician subject matter expertise.
• Adhere to compliance with NCQA, URAC, CMS, DOH and DOL standards.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Master's in MBA/Management or Public Health (preferred)

Job description

Highmark Inc. seeks an experienced physician to lead utilization management activities within a multidisciplinary team in New York. You will review escalated cases, determine medical necessity, and participate in disease management discussions with peers and specialists.

Responsibilities include policy development, adherence to NCQA/URAC/CMS regulations, and driving care improvements for members. Prior medical management experience and board certification are highly valued.