Senior Medical Director, Utilization & Care Management

Highmark Health; Baton Rouge (LA); On-site; USD 228,000 - 385,000; Full time

Job summary

Highmark Inc. is seeking a physician to lead utilization management within a multidisciplinary team. The role ensures reviews meet medical policy criteria and regulatory standards while supporting case and disease management for high-risk members.

The position requires medical board certification, active licensure, and at least five years in direct patient care. A Master’s in Business Administration or Public Health is preferred, with potential involvement in managed care projects.

Qualifications

• MD/DO required and board-certified.
• Active medical state licensure required; additional state licensure may be needed based on business need.
• Preferred Master’s degree in Business Administration/Public Health.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds.
• Develop protocols and guidelines to ensure consistency in the review process.
• Manage projects or participate in project teams as a physician subject matter expert.
• Other duties as assigned.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

MBA/MPH (preferred)

Job description

Highmark Inc. is seeking a physician to lead utilization management within a multidisciplinary team. The role ensures reviews meet medical policy criteria and regulatory standards while supporting case and disease management for high-risk members.

The position requires medical board certification, active licensure, and at least five years in direct patient care. A Master’s in Business Administration or Public Health is preferred, with potential involvement in managed care projects.