Medical Director

Overview

Highmark Inc. is seeking a physician to join a team to perform utilization management duties per current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria to evaluate medical necessity and appropriateness. Telephonic peer-to-peer discussions may be required. The physician ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations. In addition to utilization review, the physician serves as a member of the multidisciplinary team for case and disease management and may advise on high-risk cases.

The physician may be assigned special projects to support member care.

• Conduct electronic review of escalated cases against medical policy criteria, including potential telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations, reviews of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). Ensure all aspects of the medical management process align with community standards of care.
• Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the team on cases requiring physician expertise.
• Participate in protocol and guideline development to ensure consistency in the review process.
• Actively manage projects and/or participate on project teams that require a physician subject matter expert.
• Other duties as assigned.

• Required:
  
  Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

• None

• Master s Degree in Business Administration/Management or Public Health

• Required:
  
  5 years in clinical, direct patient care (hospital, outpatient, or private practice)
• Preferred: 1 year in Medical Management in a health insurance plan; strong knowledge of managed care industry

• Required:
  
  Medical Doctor or Doctor of Osteopathic Medicine (DO)
• Required:
  
  Board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
• Required:
  
  Active medical state licensure; additional state licensure may be required based on business need
• Preferred:
  None

• Critical Thinking
• Case Management
• Customer Service
• Oral and Written Communication Skills
• Collaboration
• Listening
• Telephone Skills
• General Computer Skills
• Clinical Software
• Managed Care

None

0% - 25%

• Position Type:
  Office-Based
• Teaches / trains others regularly:
  Occasionally
• Travel regularly from the office to various work sites or site-to-site
• Works primarily out-of-the office selling products/services
• Physical work site required
• Lifting: up to 10 pounds

Compliance and notices:
This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to confidential information and must protect it at all times in accordance with HIPAA and company privacy policies.

All employees must comply with the company s Code of Business Conduct and with applicable federal and state laws, as well as company policies and training requirements.

Minimum: $

Maximum: $

Base pay is determined by qualifications, experience, expected contributions, internal peer equity, market conditions, and business considerations. The displayed salary range does not reflect geographic differentials Highmark may apply for certain locations.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on protected veteran or disability status and prohibit discrimination based on any category protected by law.

Accessibility:
If you need assistance with the application process, contact HR Services Online at HRServices

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req : J266916