Medical Director

Location: Louisiana

Medical Director Skip to main content

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If you participate in the online application process through this Workday site, your personal information will be collected, including but not limited to data such as your resume and resume content, education, contact information, address, city, postal code, country, phone number, email address, IP address, as well as any other personal information you choose to provide.  As part of the online application process, we will provide details such as how we will use the data that we collect and where such information is processed.  

We will also ask for your consent to use the data for purposes contained in the Highmark Health Data Protection Statement and the GDPR Data Protection Consent for Job Applicants, and for all other permissible purposes.# Careers Medical Director page is loaded## Medical Director Apply remote type:
Remote locations:
PA, Working at Home
- Pennsylvania:
MD, Working at Home
- Maryland:
WA, Working at Home
- Washington:
NC, Working at Home - N Carolina:
LA, Working at Home
- Louisiana time type:
Full time posted on:
Posted Todayjob requisition :
J280709##
** Company :
** Highmark Inc.##
** Job Description :
**** JOB SUMMARY
** This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required.

The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the incumbent may be assigned special projects to help support and improve the care of our members
** ESSENTIAL RESPONSIBILITIES
*** Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer to peer discussions, to determine medical necessity and appropriateness. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.).

Ensure that all aspects of the medical management process are consistent with community standards of care.
* Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise multidisciplinary team on cases that require physician expertise.
* Participate in protocol and guidelines 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.
** EDUCATION
* *** Required
* ** Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
** Substitutions
* ** None
* * Preferred
* ** Master's Degree in Business Administration/Management or Public Health
** EXPERIENCE
* *** 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
** LICENSES AND CERTIFICATION
**** Required
* ** Medical Doctor or Doctor of Osteopathic Medicine (DO)
* Awarded Board Certification at least once in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
* Active medical state licensure required. Additional specific state licensure(s) may be required based on business need.
** Preferred
* ** None
* * SKILLS
* ** Critical Thinking
* Case Management
* Customer Service
* Oral & Written Communication Skills
* Collaboration* Listening
* Telephone Skills
* General Computer Skills
* Clinical Software
* Managed Care
** Language (Other than English)
** None
* * Travel Required
** 0%  - 25%
** PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
** Position Type Office-Based Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)
Never Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds Rarely
*** Disclaimer:
** The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a…